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

Alternative Preventive Options

• Mirtazapine and venlafaxine have documented efficacy as second-line options 5
• Weaker evidence exists for gabapentin, topiramate, and tizanidine 5

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as adjunctive management options 1, 2
• Lifestyle modifications including regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques should be implemented 2
• Relaxation therapies with EMG biofeedback and cognitive therapy have approximately 40-50% efficacy rates 3
• Acupuncture has documented efficacy as a non-pharmacological preventive method 5

Special Considerations

When Nausea is Present

• Add an antiemetic medication for severe attacks accompanied by nausea to improve treatment outcomes 1

Monitoring and Adjustment

• Assess response to therapy regularly and adjust treatment if inadequate pain relief is achieved 1
• If medication overuse is present, withdraw the overused medication gradually—non-opioids can be stopped abruptly or weaned within a month 2