What are the best treatments for tension headaches caused by health anxiety?

Treatment of Tension Headaches Caused by Health Anxiety

For acute tension headaches related to health anxiety, start with ibuprofen 400 mg or acetaminophen 1000 mg at headache onset, and if experiencing frequent headaches (≥2 attacks per month), initiate preventive treatment with amitriptyline starting at 10-25 mg at bedtime, titrating up to 50-100 mg as needed. 1, 2

Acute Treatment Approach

First-Line Medications

• Ibuprofen 400 mg is the preferred first-line option, showing statistically significant improvement in pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg is equally effective as an alternative, particularly if NSAIDs are contraindicated 1, 2, 3
• Take medication early in the headache episode for maximum effectiveness 1

If Initial Treatment Fails

• Consider combination analgesics with caffeine or try alternative NSAIDs such as naproxen sodium 550 mg 2
• 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 2
• Using acute treatments more than twice weekly significantly increases risk of progression to chronic daily headache 1
• Completely avoid opioids and butalbital-containing compounds due to high risk of dependence and medication overuse headache 1, 2

Preventive Treatment for Frequent Headaches

When to Initiate Prevention

Consider prophylactic treatment when you experience: 1, 4

• 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 (to prevent medication overuse headache)

Amitriptyline Protocol

• Start with 10-25 mg at bedtime, gradually titrating up to 50-100 mg as needed and tolerated 2, 4
• Amitriptyline at 50-100 mg significantly reduces monthly headache days in chronic tension-type headache 1
• Monitor closely for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1, 2

Alternative Preventive Options

• Valproate may be considered as an alternative with appropriate monitoring 4
• Avoid gabapentin (lacks efficacy evidence and has potential for misuse) 4
• Do not use botulinum toxin injections for tension-type headache prevention 4

Non-Pharmacological Interventions

Adjunctive Therapies

• Physical therapy and aerobic exercise are recommended as management options alongside medications 1, 2, 4
• Implement lifestyle modifications including regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques 2
• Greater occipital nerve blocks may provide short-term relief for refractory cases 4

Special Considerations for Health Anxiety Context

Addressing the Underlying Anxiety

Since your tension headaches stem from health anxiety, the treatment approach must address both conditions simultaneously:

• Amitriptyline serves dual purposes: it prevents tension headaches while also treating underlying anxiety and depression 1, 2
• Evaluate for comorbid psychiatric disorders that may affect treatment response 4
• Consider cognitive-behavioral therapy or relaxation training as these address both the anxiety and headache components 5

Common Pitfalls to Avoid

• Do not fall into the trap of frequent analgesic use driven by anxiety about headaches—this paradoxically worsens the condition through medication overuse headache 1, 2
• Avoid seeking reassurance through repeated medication use; instead, establish a structured preventive regimen 1
• Resist using opioids or butalbital even if anxiety makes the headaches feel unbearable—these medications significantly worsen long-term outcomes 1, 2

Treatment Algorithm Summary

1. For each acute headache: Take ibuprofen 400 mg or acetaminophen 1000 mg at onset 1, 2
2. Track frequency: If using acute medications >2 days/week, proceed to step 3 2
3. Initiate prevention: Start amitriptyline 10-25 mg at bedtime 2, 4
4. Titrate gradually: Increase to 50-100 mg over several weeks based on response and tolerability 1, 2
5. Monitor effects: Assess for anticholinergic side effects and headache frequency reduction 1, 2
6. Add non-pharmacological approaches: Incorporate physical therapy, aerobic exercise, and stress management techniques 2, 4