What is the recommended treatment for a patient presenting with a tension headache, considering their medical history and potential underlying conditions?

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 starting at 10-25 mg at bedtime and titrate to 50-100 mg. 1, 2

Acute Treatment Algorithm

First-line therapy:

• Ibuprofen 400 mg is the preferred initial treatment, showing statistically significant pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg is equally effective as an alternative option 1, 2
• Take medication early in the headache episode for maximum effectiveness 1

Second-line options if inadequate relief:

• Consider combination analgesics containing caffeine, which are slightly superior to simple analgesics 3, 4
• Alternative NSAIDs such as naproxen sodium 550 mg can be tried 1
• Ketoprofen 50-75 mg or naproxen 550-825 mg are additional NSAID options 3

Critical pitfall to avoid:

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

Medications to avoid:

• Never use opioids due to high risk of dependence and medication-overuse headache 1, 2
• Avoid butalbital-containing compounds due to high risk of dependence 1
• Triptans and muscle relaxants should not be used for tension-type headache 4

Preventive Treatment Indications

Consider prophylactic treatment when:

• Two or more attacks per month producing disability lasting 3 or more days 1, 2
• Contraindication to or failure of acute treatments 1, 2
• Use of abortive medication more than twice per week 1, 2

Preventive Treatment Protocol

First-line preventive therapy:

• Amitriptyline is the drug of first choice, with efficacy documented in multiple double-blind, placebo-controlled studies 5, 4
• Start at 10-25 mg at bedtime 2
• Gradually titrate to 50-100 mg as needed and tolerated 1, 2
• Efficacy rate is approximately 40-50% 3

Monitoring for amitriptyline:

• Watch for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1, 2
• Regular assessment of treatment effectiveness and adjustment as needed 2

Second-line preventive options:

• Mirtazapine has documented efficacy 5, 4
• Venlafaxine has documented efficacy 5, 4
• Weaker evidence exists for gabapentin, topiramate, and tizanidine 5

Non-Pharmacological Approaches

Evidence-based non-drug therapies:

• EMG biofeedback has documented effect with approximately 40-50% efficacy rate 3, 4
• Cognitive-behavioral therapy and relaxation training are most likely effective 4
• Physical therapy and aerobic exercise are suggested as adjunctive management options 1, 2
• Acupuncture may be valuable but has limited robust scientific evidence 4

Lifestyle modifications:

• Regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques 2
• Identification and avoidance of trigger factors 4

Special Considerations for Severe Attacks

• For severe attacks with nausea, add an antiemetic medication to improve treatment outcomes 1
• Consider non-oral routes if nausea is prominent, though this is less commonly needed in tension-type headache compared to migraine 1

Managing Medication Overuse

If medication overuse is present:

• Gradual withdrawal of the overused medication is necessary 2
• Non-opioids can be stopped abruptly or weaned within a month 2
• Opioid medications require removal over a longer period 2