Treatment of Tension-Type Headache (Tight Band Headache)
For an adult patient with stress or anxiety presenting with a tight band headache, start with ibuprofen 400 mg or acetaminophen 1000 mg at the onset of symptoms, and if headaches become chronic (≥15 days per month for 3+ months), initiate amitriptyline for prevention. 1
Acute Treatment Approach
First-Line Pharmacotherapy
Ibuprofen 400 mg is the preferred initial treatment for acute tension-type headache, showing statistically significant improvement in pain-free response at 2 hours 1
Acetaminophen 1000 mg is an equally effective alternative when NSAIDs are contraindicated or not tolerated, demonstrating significant improvement in pain-free response at 2 hours 1
Aspirin 500-1000 mg can be used as another option, with the 1000 mg dose showing superior efficacy (75.7% response rate vs 54.5% placebo) 2
Combination Therapy for Enhanced Efficacy
Consider aspirin-acetaminophen-caffeine combination for more severe episodes, as this triple combination achieves 28.5% pain-free rate at 2 hours compared to 21.0% with acetaminophen alone 3
The combination is particularly effective even when pain is rated severe at baseline (20.2% pain-free vs 12.1% with acetaminophen alone) 3
Critical Timing and Frequency Warnings
Medications must be taken early in the headache episode for maximum effectiveness 4
Do not use acute medications more than 2 days per week - exceeding this frequency places patients at high risk for medication overuse headache and progression to chronic daily headache 4, 5
Absolutely avoid butalbital-containing compounds and opioids due to high risk of dependence and medication overuse headache 4, 5
Preventive Treatment for Chronic Tension-Type Headache
Indications for Prophylaxis
Initiate preventive therapy when the patient meets any of these criteria:
- Two or more attacks per month producing disability lasting 3+ days 4
- Contraindication to or failure of acute treatments 4
- Use of abortive medication more than twice per week 4
Recommended Preventive Agent
Amitriptyline at 50-100 mg is the first-line preventive treatment for chronic tension-type headache, significantly reducing monthly headache days 1, 4
Start with a low dose and titrate slowly upward to minimize side effects 4
Monitor carefully for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities (dry mouth, constipation, urinary retention, cognitive impairment, cardiac conduction abnormalities) 4
Treatments to Avoid
- Botulinum toxin injection is not recommended for prevention of chronic tension-type headache 1
Non-Pharmacological Interventions
Adjunctive Therapies
Physical therapy and aerobic exercise can be beneficial management options for tension-type headache, though evidence quality is lower than for medications 4, 6
Manual therapy and acupuncture show beneficial effects on headache intensity, though they are not superior to standard pharmacotherapy 6
Lifestyle Modifications for Stress-Related Headaches
Given the stress/anxiety component in this patient:
- Implement stress management with relaxation techniques or mindfulness practices 1
- Ensure sufficient and consistent sleep patterns 1
- Maintain regular meals and adequate hydration 1
- Engage in regular moderate to intense aerobic exercise 1
Common Pitfalls to Avoid
Never prescribe opioids or butalbital combinations despite patient requests - these have unacceptably high risk of dependence and medication overuse headache 4, 5
Do not allow patients to use acute treatments more than 2 days weekly without initiating preventive therapy - this is the threshold for developing chronic daily headache 4, 5
Do not assume all "band-like" headaches are tension-type - carefully exclude migraine features (unilateral, throbbing, nausea, photophobia, phonophobia) as treatment differs significantly 5
Avoid neuroimaging in patients with normal neurologic examination and typical tension-type headache features - it is not indicated and wastes resources 5