Treatment of Tension-Type Headache
For acute tension-type headache with dull pain across the forehead and back of head, start with ibuprofen 400 mg or acetaminophen 1000 mg at headache onset. 1
First-Line Acute Treatment
Ibuprofen 400 mg is the preferred initial treatment, demonstrating statistically significant pain-free response at 2 hours compared to placebo 1. This dosage can be increased to 800 mg every 6 hours if needed, not exceeding 2.4 g daily 2.
Acetaminophen 1000 mg is an equally effective alternative, showing comparable efficacy to ibuprofen with significant improvement in pain-free response at 2 hours 1, 3. Both medications are well-tolerated with similar adverse event profiles 3.
Key Treatment Principles
- Take medication early in the headache episode for maximum effectiveness 1
- Avoid using acute medications more than 2 days per week to prevent medication overuse headache, which can worsen the overall condition 1, 4
- Lower doses of acetaminophen (500-650 mg) are not superior to placebo and should not be used 5
When Initial Treatment Fails
If inadequate pain relief occurs with appropriate dosing of ibuprofen or acetaminophen:
- Consider combination therapy with caffeine-containing preparations, which are slightly superior to single agents 6
- Try alternative NSAIDs such as naproxen sodium 550 mg 1, 3
- Add an antiemetic if nausea is present to improve treatment outcomes 1
Preventive Treatment for Chronic Tension-Type Headache
For patients with frequent headaches (≥15 days per month), amitriptyline 50-100 mg is recommended for preventive treatment, significantly reducing monthly headache days 1.
Important Considerations for Amitriptyline
- Monitor for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1
- Amitriptyline has an efficacy rate of approximately 40-50% for chronic tension-type headache 6
- Combination of pharmacologic and non-pharmacologic therapies is more effective than either alone 7
Non-Pharmacological Approaches
Physical therapy and aerobic exercise are suggested management options, though evidence quality is lower than for medications 1, 7. Relaxation therapies with EMG biofeedback have similar efficacy rates (40-50%) to tricyclic antidepressants 6.
Critical Pitfalls to Avoid
Do not use opioids or butalbital-containing compounds for tension-type headache due to high risk of dependence and medication overuse headache 1, 4. While these agents may provide short-term relief, they significantly increase the risk of progression to chronic daily headache 4.
Avoid frequent use of any acute medication (more than 2 days weekly), as this places patients at substantial risk for medication overuse headache and headache chronification 1, 4, 6.