Treatment of Tension-Type Headache
For acute tension headaches, start with ibuprofen 400 mg or acetaminophen 1000 mg at headache onset, and for chronic tension headaches 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 acute therapy should be ibuprofen 400 mg or acetaminophen 1000 mg taken early in the headache episode for maximum effectiveness. 1, 2 Both medications demonstrate statistically significant improvement in pain-free response at 2 hours and are clinically equivalent in efficacy 1, 3.
Alternative Acute Options
- If initial treatment provides inadequate relief, consider combination analgesics with caffeine or switch to alternative NSAIDs such as naproxen sodium 550 mg 1, 4
- For severe attacks with nausea, add an antiemetic medication to improve treatment outcomes 1
- Higher doses of ibuprofen (up to 800 mg) or naproxen (up to 825 mg) may be used if standard doses are insufficient 4
Critical Medication Overuse Warning
Limit acute medication use to no more than 2 days per week to prevent medication overuse headache and progression to chronic daily headache. 1, 2 Using acute treatments more than twice weekly significantly increases the risk of chronification 1, 5.
Absolutely avoid opioids and butalbital-containing compounds due to high risk of dependence and medication overuse headache 1, 2, 5.
Preventive Treatment
Indications for Prophylaxis
Consider preventive therapy 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
First-Line Preventive Agent
Amitriptyline is the most effective and well-researched prophylactic medication for chronic tension-type headache. 1, 2, 6
Dosing algorithm: 2
- Start at 10-25 mg at bedtime
- Gradually titrate upward as tolerated
- Target dose typically 50-100 mg for optimal efficacy
- Allow 3-4 months to reach maximal effectiveness 7
Important Monitoring Considerations
Be vigilant for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1, 2. These include dry mouth, constipation, urinary retention, and cognitive effects.
Alternative Preventive Options
If amitriptyline is not tolerated or effective, consider mirtazapine or venlafaxine, which have documented efficacy 6. Weaker evidence exists for gabapentin, topiramate, and tizanidine 6.
Non-Pharmacological Interventions
Physical therapy and aerobic exercise should be recommended as adjunctive management options 1, 2. Additional beneficial lifestyle modifications include: 7, 2
- Regular meals and adequate hydration
- Sleep hygiene improvement
- Limiting caffeine intake
- Stress management techniques (cognitive-behavioral therapy, mindfulness, yoga)
- Relaxation therapies with EMG biofeedback (40-50% efficacy rate) 4
Note that evidence for non-pharmacological interventions is generally of lower quality than for medications 1.
Managing Medication Overuse
If medication overuse headache has developed, withdrawal is essential for treatment success 7:
- Non-opioids and triptans can be stopped abruptly or weaned within one month 7, 2
- Opioid medications require gradual removal over a longer period 7, 2
- At least one month medication-free is needed to determine effectiveness 7
- Successfully removing excessive analgesic use significantly improves headaches 7
Common Pitfalls to Avoid
- Do not prescribe opioids for tension-type headache under any circumstances 1, 2
- Avoid butalbital compounds despite their short-term effectiveness due to high dependence risk 1, 5
- Do not delay preventive treatment in patients with frequent headaches—early introduction is beneficial 7
- Do not use acute medications more than 2 days weekly as this creates a vicious cycle of worsening headaches 1, 2