Treatment of Recurrent Dull Headaches in a Female in Her 30s
For a woman in her 30s experiencing dull headaches a couple times per month (consistent with episodic tension-type headache), start with over-the-counter NSAIDs (ibuprofen 400-600 mg or naproxen 500 mg) or acetaminophen 1000 mg at headache onset, and strictly limit use to no more than 2 days per week to prevent medication-overuse headache. 1
Diagnostic Clarification
This presentation—bilateral dull headache occurring infrequently (a couple times monthly)—is most consistent with episodic tension-type headache rather than migraine, which typically presents with moderate-to-severe throbbing pain, unilateral location, and associated symptoms like nausea or photophobia. 2, 1 The frequency (2 times per month) falls well below the threshold requiring prophylactic therapy.
First-Line Acute Treatment Algorithm
Initial Treatment Options
Simple analgesics are the foundation of treatment: Start with either ibuprofen 400-600 mg, naproxen 500 mg, or acetaminophen 1000 mg at headache onset. 1
Combination therapy enhances efficacy: If simple analgesics provide inadequate relief after 2-3 headache episodes, switch to a fixed combination of acetylsalicylic acid 250 mg + acetaminophen 250 mg + caffeine 65 mg, which is significantly superior to acetaminophen alone (28.5% vs 21.0% pain-free at 2 hours). 3
Caffeine provides synergistic benefit: The addition of caffeine to analgesics enhances absorption and provides independent analgesic effects, making combination products more effective than monotherapy. 3
Critical Frequency Limitation
Never exceed 2 days per week of analgesic use: Using pain relievers more than twice weekly places patients at significant risk for progression to chronic daily headache and medication-overuse headache. 1 This is the single most important pitfall to avoid in tension-type headache management.
Medication-overuse headache threshold varies by drug class: NSAIDs cause medication-overuse headache at ≥15 days per month, while combination analgesics have a lower threshold. 4
When to Escalate Treatment
Consider Prophylactic Therapy If:
Headaches occur more than twice weekly or last more than 2 days despite acute treatment. 2
The patient is using acute medications more than 2 days per week, indicating inadequate control. 1
First-Line Prophylactic Agent:
Amitriptyline is the drug of choice for prophylaxis of frequent tension-type headaches, with the most robust evidence from multiple double-blind, placebo-controlled studies. 2, 5 Typical dosing starts at 10-25 mg at bedtime and titrates up to 30-150 mg daily based on response.
Alternative prophylactic agents with documented efficacy include mirtazapine and venlafaxine, though evidence is weaker for gabapentin, topiramate, and tizanidine. 5
Important Clinical Distinctions
This is NOT Migraine Management:
The 2025 American College of Physicians migraine guidelines 4 recommend triptan + NSAID combinations for moderate-to-severe migraine, but these recommendations do not apply to tension-type headache, which lacks the characteristic features of migraine (throbbing quality, unilateral location, nausea, photophobia). 2, 1
Avoid These Common Pitfalls:
Do not prescribe butalbital-containing compounds or opioids for tension-type headache, as they carry increased risk of medication-overuse headache and dependency without superior efficacy. 4, 1
Do not add antiemetics routinely unless nausea is present, which is atypical for tension-type headache. 1
Do not order neuroimaging in the absence of red flags (sudden onset, progressive worsening, focal neurologic signs, fever, or change in headache pattern). 1
Non-Pharmacological Adjuncts
Lifestyle modifications should be emphasized: Maintain regular sleep schedule, adequate hydration, regular meals, and stress management through relaxation techniques or mindfulness. 4
Evidence-based non-pharmacological options include biofeedback, relaxation training, and cognitive therapy, though large rigorous trials are lacking. 1, 5
Acupuncture has documented efficacy as a prophylactic modality for tension-type headache. 5
Practical Treatment Summary for This Patient
Given the low frequency (2 times per month), this patient needs acute treatment only, not prophylaxis:
First choice: Ibuprofen 400-600 mg or naproxen 500 mg at headache onset. 1
If inadequate response after 2-3 episodes: Switch to combination product (aspirin + acetaminophen + caffeine). 3
Reinforce frequency limit: Maximum 2 days per week of any analgesic use. 1
Reassess in 2-3 months: If frequency increases to >2 times weekly, initiate amitriptyline prophylaxis. 2