What are the treatment options for tension type headache?

Treatment Options for Tension-Type Headache

Acute Treatment

For acute tension-type headache, use ibuprofen 400 mg or acetaminophen 1000 mg as first-line therapy, both showing significant pain-free response at 2 hours. 1, 2, 3

First-Line Acute Medications

• Ibuprofen 400 mg is the preferred NSAID for short-term treatment 1, 2, 3
• Acetaminophen 1000 mg is equally effective as an alternative 1, 2, 3
• Both medications demonstrate superior efficacy compared to lower doses 4

Second-Line Acute Options

• Combination analgesics containing caffeine may provide slightly better relief but should be used sparingly (no more than 2 days per week) to prevent medication overuse headache 2, 5
• Other NSAIDs including naproxen (550-825 mg) or ketoprofen (50-75 mg) can be considered if first-line agents fail 4

Critical Medication Overuse Warning

• Limit acute medication use to no more than 2 days per week to prevent progression to chronic daily headache and medication overuse headache 2, 5
• Using pain relievers more than twice weekly significantly increases risk of chronification 6

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Preventive Treatment for Chronic Tension-Type Headache

Amitriptyline is the first-line preventive medication for chronic tension-type headache, with the strongest evidence base from multiple controlled trials. 1, 2, 3, 7, 5

Amitriptyline Dosing Protocol

• Start at 10-25 mg at bedtime 2, 3
• Gradually titrate upward to 50-100 mg as needed and tolerated 2, 3
• Monitor for anticholinergic side effects (dry mouth, constipation, urinary retention, sedation) 2
• Efficacy rate approximately 40-50% 4

Alternative Preventive Medications

• Mirtazapine or venlafaxine are second-line options when amitriptyline fails or is not tolerated 7, 5
• Valproate may be considered as an alternative with weak supporting evidence 3
• Weaker evidence exists for gabapentin, topiramate, and tizanidine 7

Medications to Avoid

• Botulinum toxin injections are NOT recommended for chronic tension-type headache prevention (weak against recommendation) 1, 3
• Gabapentin is NOT recommended due to lack of efficacy and potential for misuse 3
• Opioids should be avoided due to dependence risk and medication overuse headache 2

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Non-Pharmacological Interventions

Physical therapy and aerobic exercise are recommended as adjunctive management, with moderate evidence supporting their use. 1, 2, 3

Evidence-Based Non-Pharmacological Options

• Physical therapy is suggested for management of tension-type headache 1, 3
• Aerobic exercise or progressive strength training for prevention 1, 3
• EMG biofeedback has documented efficacy (40-50% response rate, similar to tricyclics) 4, 5
• Cognitive-behavioral therapy and relaxation training are likely effective 5

Interventions with Insufficient Evidence

• Acupuncture may be valuable but lacks robust scientific evidence 1, 7, 5
• Mindfulness-based therapies have insufficient evidence 1
• Yoga and dry needling have insufficient evidence 1

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Procedural Interventions

Greater Occipital Nerve Block

• Suggested for short-term treatment of tension-type headache (weak for recommendation) 1, 3
• Insufficient evidence for prevention of chronic tension-type headache 1

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Special Considerations for Chronic Tension-Type Headache

When Standard Treatment Fails

For patients with chronic tension-type headache not responding to amitriptyline:

1. Confirm diagnosis and rule out medication overuse headache (>4 days/week of acute medication use) 3
2. Optimize acute therapy with proper dosing of ibuprofen 400 mg or acetaminophen 1000 mg 3
3. Consider combination therapy: Tricyclic antidepressant plus stress management therapy produces clinically significant reductions (≥50%) in 64% of patients versus 38% with medication alone 8
4. Trial alternative preventive: Mirtazapine, venlafaxine, or valproate 3, 7, 5
5. Consider greater occipital nerve block for short-term relief 3
6. Evaluate for comorbidities: Psychiatric disorders and sleep disturbances may affect treatment response 3

Lifestyle Modifications

• Regular meals and adequate hydration 2
• Sleep hygiene improvement 2
• Stress management techniques 2
• Identification and avoidance of trigger factors 5, 6

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Treatment Algorithm Summary

For Episodic Tension-Type Headache:

• Use ibuprofen 400 mg or acetaminophen 1000 mg at headache onset 1, 2, 3
• Limit use to ≤2 days per week 2, 5
• Add non-pharmacological approaches (exercise, stress management) 2, 3

For Chronic Tension-Type Headache:

• Initiate amitriptyline 10-25 mg at bedtime, titrate to 50-100 mg 1, 2, 3
• Continue acute therapy for breakthrough headaches (within frequency limits) 3
• Add physical therapy and aerobic exercise 1, 3
• Consider EMG biofeedback or cognitive-behavioral therapy 4, 5
• If inadequate response after 6-8 weeks at therapeutic dose, switch to mirtazapine or venlafaxine 7, 5

Common Pitfalls to Avoid:

• Overuse of acute medications leading to medication overuse headache 2, 5, 6
• Using botulinum toxin for tension-type headache (ineffective) 1, 3
• Prescribing opioids (risk of dependence and chronification) 2
• Inadequate dosing or duration of preventive medication trial 2, 3