What are the treatment options for tension headaches?

Treatment of Tension-Type Headache

Acute Treatment

For acute tension-type headache, use ibuprofen 400 mg or acetaminophen 1000 mg at the onset of symptoms, both showing significant pain-free response at 2 hours. 1, 2, 3

First-Line Acute Medications

• Ibuprofen 400 mg is the preferred first-line option, demonstrating statistically significant improvement in pain-free response at 2 hours 1, 2, 3

  • Shows faster onset with significantly greater pain relief at 1 hour compared to acetaminophen 4
  • Monitor for cardiovascular risks in patients with known CV disease, hypertension, or heart failure 5
  • Avoid in patients post-CABG surgery or recent MI 5

• Acetaminophen 1000 mg is an equally effective alternative for acute treatment 1, 2, 3

  • Provides pain-free or mild pain response at 2 hours with NNT of 10 6
  • Better safety profile for patients with cardiovascular comorbidities or GI risk factors 6
  • Lower doses (500-650 mg) are not superior to placebo 6

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 2, 3, 7
• Avoid butalbital-containing compounds entirely due to high risk of dependence and medication overuse headache 2
• Avoid opioids completely for tension-type headache due to dependence risk and medication overuse potential 2, 3

Rescue Strategies for Inadequate Response

• Add an antiemetic medication for severe attacks with nausea 2
• Consider combination therapy with caffeine-containing preparations 2
• Try alternative NSAID such as naproxen sodium 550 mg 2

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Preventive Treatment for Chronic Tension-Type Headache

Amitriptyline at 50-100 mg is the recommended preventive treatment for chronic tension-type headache, significantly reducing monthly headache days. 1, 2, 3

Indications for Preventive Therapy

Consider prophylactic treatment when patients have: 2, 7

• 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 Protocol

• Start with 10-25 mg at bedtime and gradually titrate upward 3, 8
• Target dose typically 50-100 mg per day for maintenance 1, 2, 8
• For outpatients, may start with 50-100 mg at bedtime and increase by 25-50 mg increments as needed 8
• Maximum dose up to 150 mg per day for outpatients; hospitalized patients may require up to 200-300 mg daily 8
• Therapeutic effect may take up to 30 days to develop 8

Monitoring and Precautions with Amitriptyline

• Monitor carefully for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1, 2, 3
• Elderly patients require lower dosages (10 mg three times daily with 20 mg at bedtime) and careful monitoring with plasma level determination as clinically appropriate 8
• Continue maintenance therapy for 3 months or longer to prevent relapse 8

Alternative Preventive Options

• Valproate may be considered as an alternative with appropriate monitoring 7
• Memantine has shown efficacy for prevention and may be considered for refractory cases 7
• Gabapentin is NOT recommended based on lack of efficacy evidence and potential for misuse 1, 7

What NOT to Use for Prevention

• Botulinum toxin injections (onabotulinumtoxinA or abobotulinumtoxinA) are NOT recommended for chronic tension-type headache prevention 7
  • Note: These are effective for chronic migraine but not for tension-type headache

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Non-Pharmacological Approaches

Physical therapy and aerobic exercise are recommended as adjunctive management options for tension-type headache. 1, 2, 3, 7

Evidence-Based Non-Pharmacological Options

• Physical therapy as adjunctive therapy with moderate evidence quality 7
• Aerobic exercise or progressive strength training for prevention of chronic tension-type headache 7
• Lifestyle modifications including regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques 3

Important Caveat

• Evidence for non-pharmacological interventions is generally of lower quality than for medications 2
• These should be used as adjuncts to, not replacements for, appropriate pharmacological therapy

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Treatment Algorithm

For Acute Episodes:

1. Administer ibuprofen 400 mg OR acetaminophen 1000 mg at onset of headache 2, 3, 7
2. If inadequate relief, consider combination analgesics with caffeine or alternative NSAID 2, 3
3. Add antiemetic if nausea present 2
4. Assess response and adjust therapy as needed 2

For Chronic Tension-Type Headache:

1. Confirm diagnosis and rule out medication overuse headache (>4 days/week of acute medication use) 7
2. Optimize abortive therapy with proper dosing of ibuprofen 400 mg or acetaminophen 1000 mg 7
3. Initiate amitriptyline 10-25 mg at bedtime, gradually increase to 50-100 mg 3, 8
4. Monitor for anticholinergic side effects and adjust dosing accordingly 2, 3
5. If inadequate response, consider alternative preventive medication such as valproate 7
6. Consider procedural intervention such as greater occipital nerve block for short-term relief 7
7. Evaluate for comorbidities including psychiatric disorders and sleep disturbances 7
8. Add physical therapy and aerobic exercise as adjunctive therapy 3, 7