What are the appropriate management and treatment options for a patient presenting with tension headaches?

Management 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 50-100 mg daily. 1, 2

Acute Treatment

First-Line Therapy

• Ibuprofen 400 mg is the preferred first-line treatment, demonstrating statistically significant pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg is an equally effective alternative for acute episodes, also showing significant improvement in pain-free response at 2 hours 1, 2
• Take medication early in the headache episode for maximum effectiveness 1

Important Dosing Considerations

• Acetaminophen doses of 500-650 mg are not superior to placebo and should not be used 3
• Ibuprofen 400 mg has an NNT of 22 for pain freedom at 2 hours and NNT of 10 for pain-free or mild pain at 2 hours 3

Combination and Alternative Options

• If inadequate response to initial treatment, consider combination therapy with caffeine-containing preparations or alternative NSAIDs such as naproxen sodium 550 mg 2
• For severe attacks with nausea, add an antiemetic medication to improve treatment outcomes 2

Critical Medication Overuse Warning

• Limit acute medication use to no more than 2 days per week to prevent medication overuse headache 2
• Using acute treatments more than twice weekly increases risk of progression to chronic daily headache 1, 2
• Avoid butalbital-containing compounds entirely due to high risk of dependence and medication overuse headache 1
• Avoid opioids completely for tension-type headache due to risk of dependence and medication overuse 2

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
• Risk of medication overuse headache

First-Line Preventive Agent

• Amitriptyline is the recommended first-line preventive medication at doses of 50 mg and 100 mg, significantly reducing monthly headache days in chronic tension-type headache 1, 2
• Start with low doses of 10-25 mg at bedtime, gradually titrating up to 50-100 mg as needed and tolerated 2
• Preventive medications take 3-4 months to reach maximal efficacy 4

Monitoring for Amitriptyline

• Be aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1
• Monitor for signs of hepatotoxicity (nausea, fatigue, lethargy, pruritus, jaundice, right upper quadrant tenderness, flu-like symptoms) 5
• Regularly assess treatment effectiveness and adjust therapy as needed 2

Anticholinergic Side Effects to Monitor

Amitriptyline can cause: 6

• Dry mouth, constipation, urinary retention
• Confusion, disturbed concentration (especially in elderly)
• Cardiac dysrhythmias and QRS prolongation
• Drowsiness and sedation

Non-Pharmacological Approaches

• Physical therapy and aerobic exercise are recommended as adjunctive management options 1, 2
• Implement lifestyle modifications including: 4, 2
  • Regular meals and adequate hydration
  • Sleep hygiene improvement
  • Stress management techniques (yoga, cognitive-behavioral therapy, mindfulness)
  • Limiting caffeine intake
• Evidence for non-pharmacological interventions is generally of lower quality than for medications 1

Treatment Algorithm

For Episodic Tension-Type Headache

1. Use ibuprofen 400 mg or acetaminophen 1000 mg at onset 1, 2
2. If inadequate relief, consider combination analgesics with caffeine or alternative NSAIDs 2
3. Strictly limit use to ≤2 days per week to prevent medication overuse headache 2

For Chronic Tension-Type Headache

1. Start amitriptyline 10-25 mg at bedtime 2
2. Gradually increase to effective dose (typically 50-100 mg) 1, 2
3. Monitor for anticholinergic side effects and adjust accordingly 1
4. Continue for adequate trial of 3-4 months before assessing efficacy 4
5. Add lifestyle modifications and non-pharmacological approaches 2

Common Pitfalls to Avoid

• Never prescribe opioids or butalbital compounds - these create dependence and worsen headache patterns 1, 2
• Do not use acetaminophen doses below 1000 mg - they lack efficacy 3
• Avoid allowing patients to use acute medications more than 2 days weekly without initiating prevention 2
• Do not discontinue preventive therapy prematurely - allow 3-4 months for full effect 4
• In elderly patients, start amitriptyline at lower doses due to increased anticholinergic sensitivity 1