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

Treatment of Tension-Type Headache

Acute Treatment

For acute tension-type headache, start with ibuprofen 400 mg at the onset of headache, which provides superior pain relief compared to acetaminophen and achieves pain-free response at 2 hours. 1, 2

First-Line Options

• 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 for patients who cannot tolerate NSAIDs, showing significant improvement in pain-free response at 2 hours 1, 2
• Higher doses of ibuprofen (400-800 mg) are more effective than aspirin or paracetamol alone 3

Timing and Administration

• Take medications early in the headache episode for maximum effectiveness 1
• For severe attacks with nausea, add an antiemetic medication to improve treatment outcomes 1

Alternative Options if Initial Treatment Fails

• Consider combination therapy with caffeine-containing preparations if inadequate relief is obtained 1
• Try alternative NSAIDs such as naproxen sodium 550 mg 1
• Ketoprofen 50-75 mg is another effective option 3

Critical Medication Overuse Warning

Limit use of acute headache medications to no more than 2 days per week to prevent medication overuse headache 2. Using acute treatments more than twice weekly significantly increases the risk of progression to chronic daily headache 1, 4.

Medications to Avoid

• Avoid opioids due to high risk of dependence and medication overuse headache 2
• Avoid butalbital-containing compounds due to high risk of dependence and medication overuse headache 1

Preventive Treatment

For chronic tension-type headache (≥15 headache days per month) or frequent episodic headache requiring acute medication more than twice weekly, initiate amitriptyline starting at 10-25 mg at bedtime, gradually titrating to 50-100 mg as needed. 1, 2

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
• Risk of medication overuse headache

Amitriptyline Dosing Protocol

• Start at 10-25 mg at bedtime 2
• Gradually titrate up to 50-100 mg as needed and tolerated 1, 2
• Both 50 mg and 100 mg doses significantly reduce monthly headache days in chronic tension-type headache 1
• Efficacy rate is approximately 40-50% 3

Monitoring for Adverse Effects

Be aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1. Monitor for: 1, 2

• Dry mouth
• Constipation
• Urinary retention
• Sedation
• Cardiac conduction abnormalities

Alternative Preventive Agents

If amitriptyline is not tolerated or effective: 5

• Mirtazapine has documented efficacy
• Venlafaxine has documented efficacy
• Weaker evidence exists for gabapentin, topiramate, and tizanidine

Non-Pharmacological Approaches

Physical therapy and aerobic exercise are recommended as adjunctive management options 1, 2, though evidence quality is generally lower than for medications 1.

Additional beneficial approaches include: 2

• Regular meals and adequate hydration
• Sleep hygiene improvement
• Stress management techniques
• Relaxation therapies with EMG biofeedback (40-50% efficacy rate) 3

Treatment Algorithm Summary

For Episodic Tension-Type Headache:

1. Use ibuprofen 400 mg or acetaminophen 1000 mg at onset 1, 2
2. If inadequate relief, try combination analgesics with caffeine or alternative NSAIDs 1
3. Add antiemetic if nausea is present 1
4. Never exceed 2 days per week of acute medication use 2

For Chronic Tension-Type Headache:

1. Initiate amitriptyline 10-25 mg at bedtime 2
2. Gradually increase to 50-100 mg over weeks to months 1, 2
3. Monitor for anticholinergic side effects 1
4. Continue acute treatment as needed, but limit frequency 2
5. Add physical therapy and aerobic exercise 1, 2

Key Pitfalls to Avoid

• Do not use acute medications more than 2 days per week - this is the most common cause of transformation to chronic daily headache 1, 2
• Avoid prescribing opioids or butalbital compounds despite patient requests 1, 2
• Do not delay preventive treatment in patients with frequent headaches - early intervention prevents chronification 1
• In patients taking low-dose aspirin for cardioprotection, be aware that ibuprofen can interfere with aspirin's antiplatelet effect; dose aspirin at least 2 hours before ibuprofen 6