What are the recommended management strategies for tension headaches?

Management of Tension-Type Headache

For acute tension-type headache, use NSAIDs (ibuprofen 400-800mg, naproxen 550-825mg, or ketoprofen 50-75mg) as first-line treatment, and for chronic tension-type headache requiring prevention, initiate amitriptyline as the first-choice medication while implementing physical therapy or aerobic exercise as adjunctive therapy. 1, 2, 3, 4

Acute Treatment Strategy

For episodic tension-type headache attacks:

• NSAIDs are more effective than aspirin or acetaminophen and should be used as first-line agents 2

  • Ibuprofen 400mg is recommended for acute treatment 1
  • Alternative NSAIDs include naproxen 550-825mg or ketoprofen 50-75mg 2
  • Acetaminophen 1000mg can be used as an alternative when NSAIDs are contraindicated 1

• Avoid caffeine-containing combination analgesics despite their slightly superior efficacy, as frequent use promotes headache chronification and medication overuse 2

• Critical medication overuse prevention: Limit simple analgesics to fewer than 15 days per month 1

  • Medication overuse headache significantly worsens outcomes and prevents effectiveness of preventive treatments 1
  • Opioids should never be prescribed for tension-type headache 1, 5

Preventive Treatment for Chronic Tension-Type Headache

Pharmacologic prevention is indicated when headaches are frequent, difficult to treat, or causing significant disability.

First-Line Preventive Medication

• Amitriptyline is the first-choice preventive medication with efficacy documented in multiple double-blind, placebo-controlled studies 3, 4
  • Efficacy rate approximately 40-50% 2
  • Start slowly and titrate to therapeutic tolerated dose over 3 months for adequate therapeutic trial 1
  • Caution: May cause weight gain and should be used carefully in patients with depression comorbidity 1

Alternative Preventive Medications

• Mirtazapine or venlafaxine are documented alternatives to tricyclic antidepressants 4

  • Venlafaxine is weight neutral and helpful with comorbid depression symptoms 1

• Weaker evidence supports: gabapentin, topiramate, and tizanidine 4

  • Topiramate may help with weight loss but requires counseling about depression, cognitive slowing, and contraceptive pill interaction 1, 5

Combined Therapy Approach

The combination of tricyclic antidepressant medication plus stress management therapy is superior to either treatment alone:

• Combined therapy produces clinically significant (≥50%) headache reduction in 64% of patients compared to 38% with antidepressant alone, 35% with stress management alone, and 29% with placebo 3
• Antidepressant medication yields more rapid improvements in headache activity 3
• Combined therapy is recommended for most patients with chronic tension-type headache 6

Non-Pharmacologic Interventions

Physical therapy and exercise have documented efficacy and should be implemented:

• Physical therapy is recommended for management of tension-type headache 1
• Aerobic exercise or progressive strength training is recommended for prevention 1

Behavioral interventions with documented efficacy:

• Relaxation therapies with EMG biofeedback have approximately 40-50% efficacy rate, similar to tricyclic antidepressants 2, 6
• Stress management therapy (relaxation, cognitive coping) is modestly effective 3
• Acupuncture has documented efficacy for tension-type headache 4

Note: There is insufficient evidence to definitively recommend for or against cognitive behavioral therapy, mindfulness-based therapies, or progressive muscle relaxation, though these may be considered 1

Essential Lifestyle Modifications

Implement these foundational strategies for all patients with tension-type headache:

• Limit caffeine intake 1, 5
• Ensure regular meals and adequate hydration 1, 5
• Maintain consistent sleep schedule and good sleep hygiene 1, 5
• Regular exercise program 1, 5
• Stress management techniques (yoga, cognitive-behavioral therapy, mindfulness) 1

Treatment Algorithm

1. For acute episodes: Start with NSAIDs (ibuprofen 400mg preferred) or acetaminophen 1000mg 1, 2

2. For frequent or chronic tension-type headache:

   • Initiate amitriptyline as first-line preventive medication 3, 4
   • Add stress management therapy for optimal outcomes 3
   • Implement physical therapy or aerobic exercise program 1
   • Ensure comprehensive lifestyle modifications 1, 5

3. If amitriptyline fails or is not tolerated: Consider mirtazapine or venlafaxine 4

4. Monitor closely for medication overuse: Keep analgesic use below 15 days per month 1

Common pitfall: The pathogenesis of tension-type headache involves both peripheral mechanisms (myofascial nociception) and central mechanisms (sensitization and inadequate endogenous pain control), with central mechanisms predominating in chronic forms 6. This explains why chronic tension-type headache is particularly difficult to treat and why combined pharmacologic and non-pharmacologic approaches are necessary for optimal outcomes.