How to manage tension headaches in a patient?

Management of Tension-Type Headache

For acute tension-type headache, use NSAIDs as first-line therapy (ibuprofen 400-800mg or naproxen 550-825mg), and for patients with frequent episodes (≥2 per week), initiate amitriptyline as preventive therapy while limiting acute medication use to fewer than 15 days per month to avoid medication overuse headache. 1

Acute Treatment Approach

First-line acute therapy:

• Ibuprofen 400-800mg is the preferred initial treatment for acute tension-type headache episodes 1, 2
• Naproxen 550-825mg or ketoprofen 50-75mg are effective alternatives 2
• Acetaminophen 1000mg can be used when NSAIDs are contraindicated, though it is less effective than NSAIDs 1, 3

Critical medication overuse prevention:

• Limit simple analgesics to fewer than 15 days per month to prevent medication overuse headache, which significantly worsens outcomes and prevents effectiveness of preventive treatments 1
• Avoid caffeine-containing preparations for frequent use, as they increase risk of headache chronification 2
• Avoid butalbital-containing compounds and opiates as they carry high risk for medication overuse headache and dependence 4

Preventive Treatment for Frequent or Chronic Tension-Type Headache

Initiate preventive therapy when:

• Headaches occur more than twice per week 5, 6
• Headaches last more than 2 days 6
• Patient is at risk for medication overuse (using acute medications >4 days per week) 3

First-line preventive medication:

• Amitriptyline is the first-choice preventive medication with documented efficacy rate of 40-50% 1, 2, 7
• Start at low dose and titrate slowly to therapeutic tolerated dose over 3 months for adequate therapeutic trial 1
• This is the most widely researched prophylactic agent with multiple double-blind, placebo-controlled studies supporting its use 7, 4

Alternative preventive medications:

• Venlafaxine is an alternative option, particularly beneficial when comorbid depression is present and is weight neutral 1, 7
• Mirtazapine has documented efficacy as an alternative antidepressant option 1, 7
• Valproate may be considered with appropriate monitoring when first-line agents fail 3

Medications NOT recommended:

• Botulinum toxin injections are specifically not recommended for chronic tension-type headache prevention 3
• Gabapentin is not recommended due to lack of efficacy evidence and potential for misuse 3

Non-Pharmacologic Interventions

Physical therapy and exercise:

• Physical therapy using combination techniques (thermal methods, trigger point massage, mobilization/manipulation) is beneficial for chronic tension-type headache prevention 1
• Aerobic exercise or progressive strength training 2-3 times per week for 30-60 minutes is recommended for prevention 1, 3
• Upper-body progressive strength training 3 times weekly for 30 minutes shows benefit 1

Behavioral interventions:

• Relaxation therapies with EMG biofeedback have efficacy rates of 40-50%, comparable to tricyclic antidepressants 2
• Cognitive therapy and self-hypnosis may be helpful adjuncts 4
• Acupuncture has documented efficacy in some studies 7

Essential Lifestyle Modifications

Key lifestyle interventions to implement:

• Limit caffeine intake to prevent rebound effects 1
• Ensure regular meals and adequate hydration 1
• Maintain consistent sleep schedule and good sleep hygiene 1
• Implement regular exercise program 1
• Identify and reduce precipitating factors 6

Treatment Algorithm

Step 1: Confirm diagnosis and assess frequency

• Rule out medication overuse headache by ensuring patient is not overusing acute medications (>15 days/month for simple analgesics) 1, 3
• Evaluate for comorbidities including psychiatric disorders and sleep disturbances which may affect treatment response 3

Step 2: Optimize acute therapy

• Use ibuprofen 400-800mg for acute episodes, taken as early as possible during attack 1, 2
• Ensure proper dosing and limit use to <15 days per month 1

Step 3: Initiate preventive therapy if indicated (≥2 headaches per week)

• Start amitriptyline as first-line preventive medication 1, 6
• Add stress management therapy 1
• Add physical therapy or aerobic exercise program for optimal outcomes 1, 3

Step 4: Consider alternatives if first-line preventive fails

• Try venlafaxine or mirtazapine as alternative preventive medications 1, 7
• Consider valproate with appropriate monitoring 3
• Greater occipital nerve blocks may provide short-term relief 3

Common Pitfalls to Avoid

Medication overuse headache is the most critical pitfall:

• This occurs with frequent use of acute medications and creates a pattern of increasing headache frequency, often resulting in daily headaches 1
• Any acute medication use more than twice weekly places patients at risk for progression to chronic daily headache 4
• Once medication overuse headache develops, preventive treatments become ineffective until the overused medication is discontinued 1

Inadequate preventive trial:

• Amitriptyline requires a full 3-month trial at therapeutic dose before determining efficacy 1
• Starting dose too high or escalating too quickly leads to intolerable side effects and treatment discontinuation 1

Using ineffective treatments:

• Avoid botulinum toxin injections as they are specifically not recommended for tension-type headache 3
• Acetaminophen alone is less effective than NSAIDs and should not be first-line 1, 2