What are the treatment options for a patient presenting with tension headaches?

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 tolerated. 1, 2

Acute Treatment

First-Line Therapy

• Ibuprofen 400 mg is the preferred first-line treatment, demonstrating statistically significant improvement in pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg is an equally effective alternative when NSAIDs are contraindicated or not tolerated, also showing significant pain-free response at 2 hours 1, 2
• Take medication early in the headache episode for maximum effectiveness 1

Second-Line Options

• If inadequate relief with initial treatment, consider combination analgesics with caffeine or try alternative NSAIDs such as naproxen sodium 550 mg 1
• For severe attacks with nausea, add an antiemetic medication to improve treatment outcomes 1

Critical Medication Overuse Warning

• Avoid using acute medications more than 2 days per week - this threshold prevents medication overuse headache 2, 3
• Using acute treatments more than twice weekly increases risk of progression to chronic daily headache 1
• Never use opioids or butalbital-containing compounds due to high risk of dependence and medication overuse headache 1, 2

Preventive Treatment

Indications for Prevention

Consider prophylactic treatment when patients meet any of these criteria: 1, 3

• 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
• Risk of medication overuse headache

First-Line Preventive Agent

• Amitriptyline is the recommended first-line preventive medication for chronic tension-type headache 1, 2
• Start at 10-25 mg at bedtime 2
• Gradually titrate to an effective dose, typically 50-100 mg as needed and tolerated 2
• Amitriptyline at 50 mg and 100 mg significantly reduces monthly headache days 1

Monitoring for Amitriptyline

• Be aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1
• Monitor for dry mouth, constipation, urinary retention, and cognitive effects 2
• Regular assessment of treatment effectiveness with adjustment as needed 2

Alternative Preventive Options

• Valproate may be considered as an alternative with a "weak for" recommendation 3
• Mirtazapine and venlafaxine have documented efficacy in some studies 4
• Do not use botulinum toxin injections - specifically not recommended for chronic tension-type headache prevention 3
• Do not use gabapentin - lacks efficacy evidence and has potential for misuse 3

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are suggested as adjunctive management options 1, 2, 3
• Progressive strength training may be used for prevention 3
• Lifestyle modifications including regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques should be implemented 2

Treatment Algorithm

For Acute Episodes:

1. Start with ibuprofen 400 mg or acetaminophen 1000 mg at onset 1, 2
2. If inadequate relief, try combination with caffeine or alternative NSAID 1
3. Add antiemetic if nausea is present 1
4. Ensure not exceeding 2 days per week of acute medication use 2

For Chronic Tension-Type Headache:

1. Confirm diagnosis and rule out medication overuse headache (ensure patient not using acute medications >2 days/week) 3
2. Optimize acute therapy dosing first 3
3. Initiate amitriptyline 10-25 mg at bedtime 2
4. Gradually increase to 50-100 mg, monitoring for anticholinergic side effects 1, 2
5. Add physical therapy and aerobic exercise as adjunctive therapy 2, 3
6. If amitriptyline fails, consider valproate with appropriate monitoring 3
7. Evaluate for psychiatric comorbidities and sleep disturbances that may affect treatment response 3

Key Contraindications and Cautions

Ibuprofen Warnings (from FDA Label)

• Monitor for cardiovascular thrombotic events including chest pain, shortness of breath, weakness 5
• Watch for GI ulceration and bleeding - can occur without warning symptoms 5
• Be alert for serious skin reactions including DRESS syndrome 5
• Monitor for heart failure symptoms including unexplained weight gain or edema 5
• Ibuprofen may interfere with antiplatelet activity of low-dose aspirin - dose aspirin at least 2 hours before ibuprofen if using for cardioprotection 5
• Use caution with ACE inhibitors, diuretics, lithium, methotrexate, and warfarin due to drug interactions 5