Management of Mild Tension-Type Headache in a Young Adult
For this 27-year-old male with a mild, stress-induced frontal headache and no red flags, the recommended first-line treatment is NSAIDs (naproxen or ibuprofen) rather than acetaminophen, as acetaminophen alone is ineffective for tension-type headache. 1
Immediate Pharmacologic Management
Your current plan appropriately includes NSAIDs, but should exclude acetaminophen monotherapy:
- Naproxen sodium 500-550mg or ibuprofen 400-600mg as needed for acute headache relief 1, 2
- Acetaminophen alone is ineffective and should not be recommended as monotherapy 1
- Limit acute treatment to no more than twice weekly to prevent medication-overuse headache 1, 3
Critical Medication Overuse Prevention
A major pitfall in managing even mild headaches is the development of medication-overuse headache:
- Using acute medications on ≥10 days per month for ≥3 months (for NSAIDs or combination analgesics) or ≥15 days per month (for simple analgesics) can transform episodic headache into chronic daily headache 1, 4
- Avoid butalbital-containing compounds entirely due to high risk of dependency and rebound headaches 3
- Avoid opioids (including tramadol) as they have high risk of dependency, rebound headaches, and loss of efficacy 3, 4
Non-Pharmacologic Interventions
Your plan appropriately addresses lifestyle modifications:
- Identify and avoid specific triggers through headache diary documentation (stress, sleep deprivation, caffeine, alcohol) 1
- Regular aerobic exercise has evidence for headache prevention 1
- Stress management techniques are particularly relevant given the work-related stress trigger 1
- Avoid tobacco and limit alcohol consumption 1
Headache Diary Implementation
The headache diary should specifically track:
- Frequency, severity (0-10 scale), and duration of each headache episode 1
- Associated symptoms (photophobia, phonophobia, nausea) to distinguish tension-type from migraine 1
- Medication use including dates and doses to monitor for overuse patterns 1, 4
- Potential triggers (stress events, sleep patterns, dietary factors) 1
Follow-Up Parameters
Your return precautions are appropriate, but add specific monitoring:
- Return in 48 hours if no improvement with current intervention (as planned) 1
- Immediate ED evaluation for thunderclap headache, altered mental status, seizure, or loss of consciousness (as planned) 1
- Consider preventive therapy if headaches occur more than twice weekly or if acute medications are needed more than twice weekly 1, 3
- Re-evaluate diagnosis if headache pattern changes or new symptoms develop, as tension-type headache can coexist with or transform into migraine 1, 4
When to Escalate Care
Refer to neurology or headache specialist if:
- Headaches become chronic (≥15 days per month for ≥3 months) 1, 5
- Poor response to appropriate acute and preventive strategies 6
- Development of medication overuse headache requiring structured withdrawal 4, 5
- Diagnostic uncertainty or atypical features emerge 6
Key Modification to Your Current Plan
Remove acetaminophen (Tylenol) from the acute treatment recommendation and use naproxen sodium or ibuprofen as monotherapy, as acetaminophen alone lacks efficacy for tension-type headache 1. The combination of acetaminophen-aspirin-caffeine has evidence for migraine but not for isolated tension-type headache 1.