What is the treatment for tension headaches?

Treatment of Tension Headaches

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

Acute Treatment

First-Line Options

• Ibuprofen 400 mg is the preferred first-line treatment, showing statistically significant improvement in pain-free response at 2 hours compared to placebo. 1, 2
• Acetaminophen 1000 mg is an equally effective alternative with similar efficacy to ibuprofen for acute episodes. 1, 2, 3
• Take medication early in the headache episode for maximum effectiveness—waiting reduces treatment response. 2

Alternative NSAIDs

• If inadequate relief with ibuprofen, consider naproxen sodium 550 mg or other NSAIDs (ketoprofen 50-75 mg). 2, 4
• Combination analgesics containing caffeine may provide slightly superior relief but should be limited to prevent medication overuse headache. 2, 4

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. 1, 2
• Using acute treatments more than twice weekly places patients at significant risk for progression to chronic daily headache. 5

Medications to Avoid

• Avoid opioids entirely due to high risk of dependence and medication overuse headache—they have no role in tension headache management. 1, 2
• Butalbital-containing compounds carry increased risk of chronic daily headache despite providing relief. 5

Preventive Treatment for Chronic Tension Headaches

When to Initiate Prevention

• Consider prophylaxis when headaches occur more than twice weekly, last more than 2 days, or cause significant disability. 6, 5
• Prevention is also indicated when acute treatments are contraindicated, ineffective, or being overused. 7

First-Line Preventive Agent

• Amitriptyline is the first-choice preventive medication, with consistent evidence from multiple controlled trials showing 40-50% efficacy rate. 1, 8, 2, 9
• Start at 10-25 mg at bedtime and gradually titrate to an effective dose, typically 50-100 mg as needed and tolerated. 1, 2
• Monitor for anticholinergic adverse effects (dry mouth, constipation, urinary retention, drowsiness), especially in elderly patients and those with cardiac comorbidities. 2

Alternative Preventive Options

• Mirtazapine and venlafaxine have documented efficacy when amitriptyline fails or is not tolerated. 9
• Valproate may be considered as an alternative with a "weak for" recommendation, though it requires appropriate monitoring for side effects including weight gain, hair loss, tremor, and teratogenic potential. 8
• Gabapentin and topiramate have weaker evidence and are not routinely recommended. 8, 9

What Does NOT Work for Prevention

• Botulinum toxin injections are specifically not recommended for chronic tension-type headache prevention—they lack efficacy evidence. 8

Non-Pharmacological Approaches

Evidence-Based Adjunctive Therapies

• Physical therapy and aerobic exercise are recommended as adjunctive management options with moderate evidence quality. 1, 8, 2
• Progressive strength training may be used for prevention of chronic tension-type headache. 8
• Relaxation therapies with EMG biofeedback show approximately 40-50% efficacy, comparable to tricyclic antidepressants. 4
• Cognitive-behavioral therapy and certain types of psychotherapy have documented efficacy. 9, 5

Lifestyle Modifications

• Implement regular meals, adequate hydration, improved sleep hygiene, and stress management techniques. 1
• Identify and avoid individual headache triggers through patient tracking. 7

Treatment Algorithm

For Episodic Tension Headaches

1. Take ibuprofen 400 mg or acetaminophen 1000 mg at headache onset. 1, 2
2. If inadequate relief, consider combination analgesics with caffeine or alternative NSAID (naproxen sodium 550 mg). 2, 4
3. For severe attacks with nausea, add an antiemetic medication to improve treatment outcomes. 2
4. Strictly limit acute medication use to ≤2 days per week. 1

For Chronic Tension Headaches

1. Confirm diagnosis and rule out medication overuse headache—ensure patient is not overusing acute medications (>2 days/week). 8
2. Optimize acute therapy dosing while maintaining frequency limits. 8
3. Initiate amitriptyline 10-25 mg at bedtime, gradually increase to effective dose (typically 50-100 mg). 1, 2
4. Monitor for anticholinergic side effects and adjust dosing accordingly. 2
5. Add physical therapy and aerobic exercise as adjunctive therapies. 1, 8
6. If amitriptyline fails after adequate trial, consider valproate or alternative antidepressants (mirtazapine, venlafaxine). 8, 9
7. Greater occipital nerve blocks may provide short-term relief when other treatments fail. 8
8. Evaluate for comorbid psychiatric disorders and sleep disturbances that may affect treatment response. 8

Key Clinical Pitfalls

• The most common error is allowing patients to overuse acute medications, which perpetuates and worsens headaches—enforce the 2-day-per-week limit strictly. 1, 2
• Starting amitriptyline at too high a dose increases side effects and reduces adherence—always start low (10-25 mg) and titrate slowly. 1, 2
• Failing to address medication overuse before initiating preventive therapy will result in treatment failure. 8
• Prescribing opioids or butalbital compounds creates dependency risk and medication overuse headache. 1, 2, 5