What are the treatment options for tension headaches?

Treatment of Tension Headaches

For acute tension headaches, use ibuprofen 400 mg or acetaminophen 1000 mg as first-line therapy, taken at headache onset; for chronic tension headaches requiring prevention, start amitriptyline 10-25 mg at bedtime and titrate to 50-100 mg as needed. 1, 2

Acute Treatment

First-Line Options

• Ibuprofen 400 mg is the preferred first-line agent, showing statistically significant improvement in pain-free response at 2 hours 1, 2, 3
• Acetaminophen 1000 mg is an equally effective alternative for acute episodes, also demonstrating significant pain-free response at 2 hours 1, 2, 4
• Acetaminophen doses of 500-650 mg are not superior to placebo and should be avoided 4
• Take medication early in the headache episode for maximum effectiveness 2

Second-Line Options for Inadequate Response

• Consider combination analgesics containing caffeine, which are slightly superior to single agents 5
• Alternative NSAIDs include naproxen sodium 550 mg 2
• For severe attacks with nausea, add an antiemetic medication 2

Critical Medication Overuse Warning

• Limit acute medication use to no more than 2 days per week to prevent medication overuse headache 1, 2
• Using acute treatments more than twice weekly increases risk of 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

Indications for Prophylaxis

Consider preventive therapy when patients have: 2

• Two or more attacks per month producing disability lasting 3 or more days
• Contraindication to or failure of acute treatments
• Use of abortive medication more than twice per week
• Medication overuse headache present or at risk

First-Line Preventive Agent

• Amitriptyline is the drug of choice for chronic tension-type headache prevention 1, 2, 7
• Start at 10-25 mg at bedtime 1, 8
• Gradually titrate to 50-100 mg as needed and tolerated 1, 2
• Monitor for anticholinergic side effects (dry mouth, constipation, urinary retention, sedation), especially in older patients and those with cardiac comorbidities 2, 8
• Therapeutic effect may take up to 30 days to develop 8
• Continue maintenance therapy for 3 months or longer to prevent relapse 8

Alternative Preventive Options for Treatment Failures

• Valproate may be considered as an alternative with weak supporting evidence 9
• Mirtazapine and venlafaxine have documented efficacy 7
• Weaker evidence exists for gabapentin, topiramate, and tizanidine 7

Agents NOT Recommended

• Botulinum toxin injections are specifically not recommended for chronic tension-type headache 9
• Gabapentin is not recommended due to lack of efficacy evidence and potential for misuse 9

Non-Pharmacological Approaches

• Physical therapy is suggested as adjunctive therapy 1, 2, 9
• Aerobic exercise or progressive strength training may be used for prevention 1, 9
• Relaxation therapies with EMG biofeedback have approximately 40-50% efficacy rate 5
• Cognitive therapy and acupuncture have documented efficacy 7
• Evidence quality for non-pharmacological interventions is generally lower than for medications 2

Treatment Algorithm

For Episodic Tension Headaches

1. Use ibuprofen 400 mg or acetaminophen 1000 mg at onset 1, 2
2. If inadequate relief, try combination analgesic with caffeine or alternative NSAID 1, 2
3. Add antiemetic if nausea present 2
4. Monitor frequency of acute medication use 1

For Chronic Tension Headaches

1. Confirm diagnosis and rule out medication overuse headache (>4 days/week of acute medication use) 9
2. If medication overuse present, withdraw overused medication (non-opioids stopped abruptly or weaned within one month; opioids removed over longer period) 1
3. Start amitriptyline 10-25 mg at bedtime 1, 2
4. Titrate gradually to effective dose (typically 50-100 mg) 1, 2
5. Monitor for anticholinergic adverse effects 2
6. Add physical therapy and aerobic exercise as adjunctive measures 1, 9
7. If amitriptyline fails or is not tolerated, consider valproate or alternative antidepressants 9, 7
8. Evaluate for comorbidities including psychiatric disorders and sleep disturbances 9

Key Pitfalls to Avoid

• Never use opioids for tension-type headache due to dependence risk and medication overuse headache 1, 2
• Do not prescribe butalbital-containing compounds as they increase risk of chronic daily headache 10, 6
• Avoid frequent use of caffeine-containing preparations as they can cause headache chronification 5
• Do not use acetaminophen doses below 1000 mg as they are ineffective 4
• Remember that ibuprofen 400 mg taken before aspirin can interfere with aspirin's antiplatelet effect in patients taking low-dose aspirin for cardioprotection; dose aspirin at least 2 hours before ibuprofen 3