What is the recommended treatment for a typical adult patient with no significant medical history suffering from tension headaches?

Treatment of Tension Headaches

For acute tension headaches, use ibuprofen 400 mg or acetaminophen 1000 mg as first-line therapy, and for chronic tension-type headache prevention, start amitriptyline at 10-25 mg at bedtime with gradual titration to 50-100 mg as needed. 1

Acute Treatment

First-Line Pharmacotherapy

• Ibuprofen 400 mg is the preferred first-line option for acute tension headache, showing significant improvement in pain-free response at 2 hours 2, 1
• Acetaminophen 1000 mg is an equally effective alternative to ibuprofen for acute treatment 2, 1
• Both medications demonstrate superiority over placebo with high-quality evidence, though acetaminophen 500-650 mg doses are not superior to placebo 3
• Naproxen 375-550 mg is also effective, with comparable efficacy to acetaminophen 1000 mg 4, 2

Treatment Algorithm for Acute Episodes

• Start with either ibuprofen 400 mg or acetaminophen 1000 mg at headache onset 1
• If inadequate relief occurs, consider combination analgesics with caffeine or alternative NSAIDs (naproxen 550-825 mg, ketoprofen 50-75 mg) 1, 5
• Avoid opioids entirely due to risk of dependence and medication overuse headache 1

Critical Medication Overuse Prevention

• Limit simple analgesics (acetaminophen, NSAIDs) to fewer than 15 days per month to prevent medication overuse headache 1
• Limit triptans to fewer than 10 days per month if used for coexisting migraine 1
• Frequent use of acute medications can perpetuate chronic headache patterns and reduce effectiveness of preventive treatments 1

Preventive Treatment for Chronic Tension-Type Headache

When to Initiate Prevention

• Consider preventive therapy when headaches occur frequently (typically ≥2 episodes per week) or when acute treatments are insufficient 1
• Prevention is particularly important when medication overuse is present or developing 1

First-Line Preventive Agent

• Amitriptyline is the recommended first-line preventive medication for chronic tension-type headache, with efficacy documented in multiple double-blind, placebo-controlled studies 2, 1, 6
• Start at 10-25 mg at bedtime and gradually titrate upward 1, 7
• Target dose is typically 50-100 mg daily, though some patients respond to 40 mg 7
• The antidepressant effect may take up to 30 days to develop 7

Monitoring and Adverse Effects

• Monitor for anticholinergic side effects including dry mouth, constipation, urinary retention, and sedation 1, 7
• Obtain ECG monitoring in elderly patients or those with cardiac risk factors, as tricyclics can prolong QRS duration and QT interval 7
• Plasma levels are generally higher in elderly patients due to decreased hepatic metabolism; dose adjustments should be based on clinical response 7

Alternative Preventive Options

• Mirtazapine and venlafaxine have documented efficacy as alternative antidepressants 6
• Weaker evidence exists for gabapentin, topiramate, and tizanidine 6
• Botulinum toxin is NOT recommended for chronic tension-type headache prevention, as it is ineffective for this indication 2, 1

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as adjunctive management options alongside pharmacotherapy 2, 1
• Relaxation therapies with EMG biofeedback have approximately 40-50% efficacy rates, comparable to tricyclic antidepressants 5
• Trigger point therapy techniques (dry needling, ischemic compression, positional relaxation) can reduce headache duration, intensity, and frequency 8
• Lifestyle modifications include regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques 1

Common Pitfalls and Caveats

Distinguishing from Migraine

• Tension headaches are typically bilateral, mild-to-moderate, pressing or tightening in quality, and lack nausea, vomiting, photophobia, or phonophobia that characterize migraine 2
• If migraine features are present, treatment algorithms differ significantly—triptans are effective for migraine but not indicated for tension headaches 2

Avoiding Treatment Escalation Errors

• Do not use triptans for tension-type headache, as they lack efficacy for this indication 2
• Combination analgesics with caffeine should be used sparingly to avoid chronification of headaches 5
• Never prescribe opioids for tension headaches due to high risk of dependence and medication overuse 1

Amitriptyline Contraindications

• Avoid in patients with recent myocardial infarction, arrhythmias, or significant cardiac conduction abnormalities 7
• Use caution in elderly patients who are at higher risk for falls, confusion, and anticholinergic toxicity 7
• Contraindicated with MAO inhibitors due to risk of hypertensive crisis 7