What are the recommended treatments for tension headaches?

Treatment of Tension-Type Headache

For acute tension-type headache, start with ibuprofen 400 mg or acetaminophen 1000 mg at headache onset; for chronic tension-type headache requiring prevention, use amitriptyline starting at 10-25 mg at bedtime and titrate to 50-100 mg as tolerated. 1, 2, 3

Acute Treatment

First-Line Pharmacotherapy

• Ibuprofen 400 mg is the preferred first-line agent, demonstrating statistically significant improvement in pain-free response at 2 hours 1, 2, 3
• Acetaminophen 1000 mg is equally effective as an alternative for acute episodes, particularly in patients who cannot tolerate NSAIDs 1, 2, 3
• Take medication early in the headache episode for maximum effectiveness 2

Second-Line Options

• If inadequate relief with monotherapy, consider combination analgesics containing caffeine or switch to alternative NSAIDs such as naproxen sodium 550 mg 2, 3
• For severe attacks with nausea, add an antiemetic medication to improve treatment outcomes 2

Critical Medication Overuse Warning

• Limit acute medication use to no more than 2 days per week to prevent medication overuse headache, which worsens the overall condition 2, 3
• Using acute medications more than 4 days per week can perpetuate chronic headaches 4

Medications to Avoid

• Avoid opioids entirely due to risk of dependence and medication overuse headache 2, 3, 4
• Do not use butalbital-containing compounds regularly despite their effectiveness, as they carry increased risk of chronic daily headache 5

Preventive Treatment for Chronic Tension-Type Headache

First-Line Prophylaxis

• Amitriptyline is the recommended preventive medication, with doses of 50-100 mg significantly reducing monthly headache days 1, 2, 3
• Start at 10-25 mg at bedtime and gradually titrate upward to an effective dose (typically 50-100 mg) as tolerated 3, 4
• Monitor carefully for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 2, 3

Alternative Preventive Options

• Valproate may be considered as an alternative with appropriate monitoring if amitriptyline fails or is not tolerated 4
• Memantine has shown efficacy for episodic migraine prevention and may be worth considering for refractory cases 4
• Mirtazapine and venlafaxine have documented efficacy as alternative antidepressants 6

Interventions NOT Recommended

• Do not use botulinum toxin injections (onabotulinumtoxinA or abobotulinumtoxinA) for chronic tension-type headache prevention, as they lack efficacy 1, 4
• Gabapentin is not recommended based on lack of efficacy evidence 4

Non-Pharmacological Approaches

Evidence-Based Modalities

• Physical therapy is suggested as adjunctive therapy with moderate evidence quality 2, 3, 4
• Aerobic exercise or progressive strength training may be used for prevention with moderate evidence 3, 4
• Relaxation therapies with EMG biofeedback have approximately 40-50% efficacy rate, comparable to tricyclic antidepressants 7
• Trigger point therapy techniques (dry needling, ischemic compression, positional relaxation) have reduced headache duration, intensity, and frequency 8

Lifestyle Modifications

• Implement regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques 3
• Address poor posture, which is associated with tension-type headaches 9

Procedural Interventions

• Greater occipital nerve blocks may provide short-term relief for refractory cases 4
• Consider this option when standard pharmacological approaches have failed 4

Treatment Algorithm for Chronic Cases

When preventive treatment is needed:

1. Confirm diagnosis and rule out medication overuse headache (ensure patient is not overusing acute medications >4 days/week) 4
2. Optimize acute therapy with proper dosing of ibuprofen 400 mg or acetaminophen 1000 mg 4
3. Initiate amitriptyline at 10-25 mg at bedtime, gradually increase to 50-100 mg, monitoring for anticholinergic side effects 3, 4
4. If amitriptyline fails, try alternative preventive medication such as valproate or mirtazapine 4, 6
5. Consider procedural intervention such as greater occipital nerve block for short-term relief 4
6. Evaluate for comorbidities including psychiatric disorders and sleep disturbances that may affect treatment response 4

Common Pitfalls

• Allowing patients to use acute medications too frequently (>2 days/week), leading to medication overuse headache and treatment failure 2, 3
• Starting amitriptyline at too high a dose, causing intolerable side effects and poor adherence 3
• Prescribing opioids or butalbital compounds, which increase risk of dependence and chronic daily headache 2, 3, 5
• Using botulinum toxin for tension-type headache when evidence shows it is ineffective 1, 4