What is the best treatment approach for a patient presenting with a tension headache?

Treatment of Tension-Type Headache

For acute tension-type headache, start with ibuprofen 400 mg or acetaminophen 1000 mg at headache onset, 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 pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg is equally effective as an alternative, also demonstrating significant improvement in pain-free response at 2 hours 1, 2
• Take medication early in the headache episode for maximum effectiveness 1

Alternative NSAIDs for Inadequate Response

• If initial treatment fails, consider naproxen sodium 550 mg or combination analgesics containing caffeine 1
• Ketoprofen 50-75 mg is another option, though caffeine-containing preparations should be used sparingly to avoid medication overuse headache 3

Critical Medication Overuse Warning

• Avoid using acute treatments more than 2 days per week to prevent medication overuse headache and progression to chronic daily headache 1, 2
• Never use butalbital-containing compounds due to high risk of dependence and medication overuse headache 1
• Avoid opioids entirely for tension-type headache due to dependence risk and medication overuse potential 1, 2

Preventive Treatment for Chronic Tension-Type Headache

Indications for Preventive Therapy

Consider prophylactic treatment 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

Amitriptyline Protocol

• Start with 10-25 mg at bedtime and gradually titrate upward 2
• Target dose is typically 50-100 mg, which significantly reduces monthly headache days 1, 2
• Monitor closely for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1
• Allow 2-3 months for full clinical benefit to manifest 4

Efficacy Expectations

• Amitriptyline achieves approximately 40-50% efficacy rate for chronic tension-type headache 3, 5
• Alternative antidepressants with documented efficacy include mirtazapine and venlafaxine, though evidence is weaker 5

Adjunctive Treatments

Non-Pharmacological Options

• Physical therapy and aerobic exercise are recommended as adjunctive management 1, 2
• Lifestyle modifications including regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques 2
• Relaxation therapies with EMG biofeedback have similar 40-50% efficacy as tricyclics 3

Severe Attacks with Nausea

• Add an antiemetic medication to improve treatment outcomes when nausea is present 1
• Consider non-oral routes if nausea is prominent early in the attack 4

Common Pitfalls to Avoid

The most critical error is overuse of acute medications, which paradoxically worsens headache frequency and can transform episodic tension-type headache into chronic daily headache. 1, 2 Patients must understand the 2-day-per-week limit strictly.

Avoid prescribing butalbital combinations or opioids, despite patient requests, as these carry unacceptably high risks of dependence and medication overuse headache. 1, 2

When initiating amitriptyline, start low and go slow with dosing, as anticholinergic side effects (dry mouth, constipation, urinary retention, cognitive impairment) can lead to discontinuation if the dose is escalated too rapidly. 1