What are the treatment options for a patient experiencing 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 50-100 mg daily. 1, 2

Acute Treatment

First-Line Options

• Ibuprofen 400 mg is the preferred first-line treatment, showing statistically significant improvement in pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg is an equally effective alternative, particularly when NSAIDs are contraindicated or not tolerated 1, 2, 3
• Take medication early in the headache episode for maximum effectiveness 1

Important Efficacy Data

• The number needed to treat (NNT) for paracetamol 1000 mg to achieve pain-free status at 2 hours is 22, while the NNT for pain-free or mild pain at 2 hours is 10 3
• Lower doses of acetaminophen (500-650 mg) are not superior to placebo and should be avoided 3
• Ibuprofen 400 mg demonstrates comparable efficacy to other NSAIDs like ketoprofen 25 mg 3

Second-Line Acute Options

• If inadequate relief with initial treatment, consider combination therapy with caffeine-containing preparations or try alternative NSAIDs such as naproxen sodium 550 mg 1, 4
• For severe attacks with nausea, add an antiemetic medication to improve treatment outcomes 1

Critical Medication Overuse Warning

• Limit acute medication use to no more than 2 days per week to prevent medication overuse headache 1, 2, 5
• Using acute treatments more than twice weekly increases risk of progression to chronic daily headache 1, 6
• NSAIDs can cause medication overuse headache when used ≥15 days per month; this threshold is lower (≥10 days per month) for triptans 7

Medications to Avoid

• Never use opioids for tension-type headache due to high risk of dependence and medication overuse headache 1, 2
• Avoid butalbital-containing compounds due to high risk of dependence and medication overuse headache 1, 6

Preventive Treatment

Indications for Prophylaxis

Consider preventive therapy when: 1, 5

• Two or more attacks per month producing disability lasting 3 or more days
• Contraindication to or failure of acute treatments
• Patient uses abortive medication more than twice per week
• Risk of medication overuse headache is present

First-Line Preventive Agent

• Amitriptyline is the drug of choice for prevention, with doses of 50 mg and 100 mg significantly reducing monthly headache days in chronic tension-type headache 1, 2, 8
• Start at low dose (10-25 mg) at bedtime and gradually titrate up to effective dose (typically 50-100 mg) 2, 8
• Monitor for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1, 2

Alternative Preventive Options

• Valproate may be considered as an alternative with a "weak for" recommendation 5
• Mirtazapine and venlafaxine have documented efficacy but are considered second-line 8
• Gabapentin is not recommended based on lack of efficacy evidence and potential for misuse 5

Interventions NOT Recommended

• Botulinum toxin injections are specifically not recommended for chronic tension-type headache prevention 5
• Cyclobenzaprine (muscle relaxant) is not indicated for tension-type headache treatment, as it acts primarily on skeletal muscle spasm rather than headache mechanisms 9

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are suggested as adjunctive management options 1, 2, 5
• Progressive strength training may be used for prevention 5
• Lifestyle modifications including regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques should be implemented 2
• Evidence quality for non-pharmacological interventions is generally lower than for medications 1

Treatment Algorithm for Chronic Tension-Type Headache

When standard treatments fail: 5

1. Confirm diagnosis and rule out medication overuse headache - ensure patient is not overusing acute medications (>4 days/week)
2. Optimize abortive therapy - ensure proper dosing of ibuprofen 400 mg or acetaminophen 1000 mg for acute episodes
3. Initiate amitriptyline - start 10-25 mg at bedtime, titrate to 50-100 mg with monitoring for anticholinergic effects
4. Consider procedural intervention - greater occipital nerve block for short-term relief if medications fail
5. Try alternative preventive medication - valproate with appropriate monitoring
6. Evaluate for comorbidities - psychiatric disorders and sleep disturbances may affect treatment response

Safety Considerations

Ibuprofen Warnings

• Monitor for cardiovascular thrombotic events (chest pain, shortness of breath) 10
• Watch for GI complications including ulceration and bleeding, which can occur without warning 10
• Be alert for serious skin reactions including DRESS syndrome 10
• Monitor for heart failure symptoms (shortness of breath, unexplained weight gain, edema) 10
• Ibuprofen may interfere with antiplatelet effects of low-dose aspirin when taken concurrently 10

Drug Interactions

• Ibuprofen may diminish antihypertensive effects of ACE-inhibitors 10
• NSAIDs can reduce natriuretic effects of diuretics 10
• Caution when combining with warfarin, methotrexate, or lithium 10