What is the recommended treatment 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, and for chronic tension-type headache requiring prevention, use amitriptyline starting at 10-25 mg at bedtime and titrate to 50-100 mg as needed. 1, 2

Acute Treatment Approach

First-Line Medications

• Ibuprofen 400 mg is the preferred first-line option, showing statistically significant improvement in pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg is an equally effective alternative with similar efficacy in achieving pain-free response at 2 hours 1, 2, 3
• Take medication early in the headache episode for maximum effectiveness 1

Second-Line Options for Inadequate Response

• Consider combination analgesics containing caffeine if initial treatment provides inadequate relief 1, 2
• Alternative NSAIDs such as naproxen sodium 550 mg can be tried 1
• For severe attacks with nausea, add an antiemetic medication to improve treatment outcomes 1

Critical Medication Overuse Warning

• Limit acute medication use to no more than 2 days per week to prevent medication overuse headache 2
• Using acute medications more than twice weekly places patients at risk for progression to chronic daily headache and worsening of the overall condition 1, 4
• Avoid opioids entirely due to risk of dependence and medication overuse headache 1, 2

Preventive Treatment for Chronic Tension-Type Headache

When to Initiate Prevention

• Consider prophylactic treatment when headaches occur more than twice weekly or last more than 2 days 5, 4
• Prevention is indicated for patients with frequent attacks that produce significant disability 1

First-Line Preventive Agent

• Amitriptyline is the recommended first-line preventive medication, with proven efficacy at 50 mg and 100 mg doses in reducing monthly headache days 1, 2, 6
• Start with 10-25 mg at bedtime and gradually titrate upward to 50-100 mg as needed and tolerated 2
• Multiple double-blind, placebo-controlled studies document amitriptyline's efficacy 6

Monitoring for Adverse Effects

• Be aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1, 2
• Regular assessment of treatment effectiveness and adjustment of therapy as needed is essential 2

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as adjunctive management options 1, 2
• Lifestyle modifications including regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques should be implemented 2
• Evidence for non-pharmacological interventions is generally of lower quality than for medications 1

Treatment Algorithm Summary

For episodic tension-type headache:

1. Use ibuprofen 400 mg or acetaminophen 1000 mg at headache onset 1, 2
2. If inadequate relief, try combination analgesics with caffeine or alternative NSAIDs 1, 2
3. Ensure medication use does not exceed 2 days per week 2

For chronic tension-type headache:

1. Initiate amitriptyline 10-25 mg at bedtime 2
2. Gradually increase to effective dose (typically 50-100 mg) 1, 2
3. Monitor for anticholinergic side effects and adjust accordingly 1, 2
4. Add physical therapy and lifestyle modifications 1, 2