What is the treatment for tension headaches?

Treatment of Tension-Type Headache

Acute Treatment

For acute tension-type headache episodes, start with ibuprofen 400 mg or acetaminophen 1000 mg at the onset of headache, both showing statistically significant improvement in pain-free response at 2 hours. 1, 2

First-Line Options

• Ibuprofen 400 mg is the preferred first-line acute treatment, demonstrating superior efficacy with rapid onset of action 1, 2
• Acetaminophen 1000 mg serves as an equally effective alternative, particularly useful in patients with contraindications to NSAIDs 1, 2, 3
• Take medication early in the headache episode for maximum effectiveness 1

Second-Line Acute Options

• If inadequate relief occurs with initial treatment, consider combination analgesics containing caffeine or switch to alternative NSAIDs such as naproxen sodium 550 mg 1, 4
• For severe attacks with nausea, add an antiemetic medication to improve treatment outcomes 1
• Naproxen 375-825 mg has demonstrated efficacy comparable to acetaminophen 1000 mg in controlled trials 3, 4

Critical Medication Overuse Warning

• Limit acute medication use to no more than 2 days per week to prevent medication overuse headache and progression to chronic daily headache 1, 2, 5
• Avoid butalbital-containing compounds due to high risk of dependence and medication overuse headache 1
• Avoid opioids for tension-type headache due to risk of dependence and medication overuse headache 1, 2

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Preventive Treatment for Chronic Tension-Type Headache

Amitriptyline at doses of 50-100 mg is the first-line preventive treatment for chronic tension-type headache, significantly reducing monthly headache days. 1, 2

Indications for Preventive Therapy

Consider prophylactic treatment when patients have: 1, 6

• 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 (risk of medication overuse headache)

Amitriptyline Dosing Strategy

• Start with 10-25 mg at bedtime 2
• Gradually titrate up to 50-100 mg as needed and tolerated 1, 2
• Monitor closely for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1, 2
• Common anticholinergic effects include drowsiness, weight gain, dry mouth, constipation, and urinary retention 7

Alternative Preventive Options

• Valproate may be considered as an alternative with appropriate monitoring for patients who fail amitriptyline 6
• Gabapentin is not recommended based on lack of efficacy evidence and potential for misuse 6
• Botulinum toxin injections are specifically not recommended for chronic tension-type headache prevention 6

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Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as adjunctive management options alongside medications 1, 2, 6
• Lifestyle modifications including regular meals, adequate hydration, sleep hygiene improvement, and stress management should be implemented 2
• Greater occipital nerve blocks may provide short-term relief for refractory cases 6

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Treatment Algorithm

For Episodic Tension-Type Headache:

1. Use ibuprofen 400 mg or acetaminophen 1000 mg at onset of headache 1, 2
2. If inadequate relief, try combination analgesics with caffeine or alternative NSAID (naproxen sodium 550 mg) 1
3. Limit use to ≤2 days per week to prevent medication overuse headache 2

For Chronic Tension-Type Headache:

1. Confirm diagnosis and rule out medication overuse headache (>4 days/week of acute medication use) 6
2. Start amitriptyline 10-25 mg at bedtime, gradually increase to 50-100 mg 2
3. Monitor for anticholinergic side effects and adjust dosing accordingly 1, 2
4. Continue optimized acute therapy for breakthrough headaches (ibuprofen 400 mg or acetaminophen 1000 mg) 6
5. Add physical therapy and aerobic exercise as adjunctive therapy 2, 6

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Important Cardiovascular and Gastrointestinal Cautions with NSAIDs

When using ibuprofen, be aware of: 8

• Increased risk of serious cardiovascular thrombotic events (MI, stroke) with NSAID use, particularly at higher doses and longer duration
• Contraindication in the setting of recent CABG surgery and use with extreme caution in patients with recent MI
• Risk of serious GI adverse events including ulceration, bleeding, and perforation, especially in elderly patients or those with prior ulcer disease
• Potential to worsen hypertension and heart failure; monitor blood pressure and avoid in severe heart failure unless benefits outweigh risks
• Use the lowest effective dose for the shortest duration possible to minimize cardiovascular and gastrointestinal risks