What is the treatment for a tension headache?

Treatment of Tension-Type Headache

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

Acute Treatment Approach

First-Line Medications

• Ibuprofen 400 mg is the preferred first-line treatment, showing statistically significant improvement in pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg is an equally effective alternative for acute episodes, with similar efficacy to ibuprofen 1, 2
• Take medication early in the headache episode for maximum effectiveness 1
• Ibuprofen can be dosed every 4-6 hours as needed, with a maximum daily dose of 3200 mg, though doses above 400 mg per episode show no additional benefit for tension headaches 3

Second-Line Options

• If inadequate relief occurs with initial treatment, consider combination analgesics with caffeine or alternative NSAIDs such as naproxen sodium 550 mg 1
• 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 and progression to chronic daily headache 1, 2
• Avoid butalbital-containing compounds entirely due to high risk of dependence and medication overuse headache 1
• Never use opioids for tension-type headache due to risk of dependence and medication overuse headache 1, 2

Preventive Treatment for Chronic Tension-Type Headache

Indications for Prophylaxis

Consider preventive therapy when patients have: 1, 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 (risk of medication overuse headache)

Amitriptyline Protocol

• Start amitriptyline at 10-25 mg at bedtime 2
• Gradually titrate to an effective dose of 50-100 mg as needed and tolerated 1, 2
• Both 50 mg and 100 mg doses significantly reduce monthly headache days in chronic tension-type headache 1
• Monitor carefully for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1, 2
• Therapeutic response may be seen within a few days to a week, but most often by two weeks 1

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as adjunctive management options 1, 2
• Lifestyle modifications include regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques 2
• Evidence for non-pharmacological interventions is generally of lower quality than for medications 1

Monitoring and Adjustment

• Assess response to therapy regularly and adjust treatment if inadequate pain relief is achieved 1, 2
• Monitor for medication overuse patterns and anticholinergic adverse effects with amitriptyline 2
• If medication overuse is present, withdraw the overused medication gradually—non-opioids can be stopped abruptly or weaned within a month 2