What is the treatment of choice for tension headaches?

Treatment of Tension-Type Headache

For acute tension-type headache, ibuprofen 400 mg is the treatment of choice, with acetaminophen 1000 mg as an equally effective alternative. 1, 2

Acute Treatment Algorithm

First-Line Options

• Ibuprofen 400 mg should be taken at headache onset, demonstrating significant improvement in pain-free response at 2 hours with an NNT of 14 compared to placebo 1, 3
• Acetaminophen 1000 mg is equally effective for acute treatment, showing comparable pain-free response at 2 hours with an NNT of 22 1, 4
• Medications must be taken early in the headache episode for maximum effectiveness 1

Second-Line Options for Inadequate Response

• Consider alternative NSAIDs such as naproxen sodium 550 mg if initial treatment fails 1
• Combination analgesics containing caffeine may provide slightly superior efficacy but should be used cautiously 1, 5
• 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 pain relievers more than twice weekly places patients at significant risk for progression to chronic daily headache 6
• Avoid opioids and butalbital-containing compounds due to high risk of dependence and medication overuse headache 1, 2

Preventive Treatment for Chronic Tension-Type Headache

When to Initiate Prevention

Consider prophylactic treatment when patients experience:

• Two or more attacks per month producing disability lasting 3 or more days 7
• Contraindication to or failure of acute treatments 7
• Use of abortive medication more than twice per week 7

First-Line Preventive Agent

• Amitriptyline is the recommended first-line preventive medication 1, 2, 8
• Start at 10-25 mg at bedtime, gradually titrating to 50-100 mg as needed and tolerated 2
• Amitriptyline at 50 mg and 100 mg significantly reduces monthly headache days in chronic tension-type headache 1
• Monitor closely for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1, 2
• Efficacy rate is approximately 40-50% 5

Alternative Preventive Options

• Mirtazapine and venlafaxine have documented efficacy as second-line agents 8
• Weaker evidence exists for gabapentin, topiramate, and tizanidine 8

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as adjunctive management options 1, 2
• Relaxation therapies with EMG biofeedback have similar efficacy rates (40-50%) to tricyclic antidepressants 5
• Lifestyle modifications including regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques should be implemented 2
• Cognitive therapy and certain types of psychotherapy have documented efficacy 8

Comparative Efficacy Notes

The evidence quality is high for ibuprofen 400 mg and acetaminophen 1000 mg versus placebo 4, 3. Lower doses of acetaminophen (500-650 mg) are not superior to placebo 4. Ibuprofen 400 mg shows no significant difference from ketoprofen 25 mg, though this comparison is based on limited data 4. The global evaluation of treatment as 'very good' or 'excellent' has an NNT of 5.9 for ibuprofen 400 mg 3.