What is the appropriate treatment for tension‑type headache in a typical adult, including acute and preventive options?

Treatment of Tension-Type Headache

Acute Treatment

For acute tension-type headache, use ibuprofen 400 mg or acetaminophen 1000 mg as first-line therapy. 1

• Ibuprofen 400 mg and acetaminophen 1000 mg both demonstrate statistically significant pain-free response at 2 hours and are recommended by the 2023 VA/DoD guidelines 1
• Lower doses of acetaminophen (500-650 mg) are ineffective and should not be used 1
• Simple analgesics and NSAIDs remain the mainstay of acute treatment for episodic tension-type headache 2
• Combination analgesics containing caffeine (aspirin-acetaminophen-caffeine) are second-choice options 2

What NOT to Use for Acute Treatment

• Avoid triptans, muscle relaxants, and opioids - these are not indicated for tension-type headache 2
• Critical warning: Limit acute medication use to prevent medication-overuse headache, which develops with use ≥10 days per month for at least 3 months 2

Preventive Treatment

For chronic tension-type headache (≥15 headache days per month), amitriptyline at 50-100 mg daily is the first-line preventive medication. 1

When to Consider Preventive Therapy

• Headaches occurring ≥15 days per month for >3 months 1
• Requiring acute treatment more than 2 days per week 3
• Frequent episodic tension-type headache causing significant disability 4
• Risk of developing medication-overuse headache 4

Preventive Medication Options

First-line:

• Amitriptyline 50-100 mg daily - the only medication with consistent evidence showing significant reduction in monthly headache days 1, 2
• Start at lower doses and titrate upward based on response and tolerability 2

Second-line alternatives:

• Mirtazapine - documented efficacy in multiple studies 5, 2
• Venlafaxine - evidence supports use when amitriptyline is not tolerated 5, 2

Weaker evidence:

• Gabapentin, topiramate, and tizanidine have limited supporting data 5

Important Caveats for Amitriptyline

• Be aware of anticholinergic adverse effects, particularly in older patients and those with cardiac comorbidities 1
• Monitor for overdose potential - this is a significant safety concern 1
• Common side effects include drowsiness, weight gain, and anticholinergic symptoms (dry mouth, constipation, urinary retention) 1

What Does NOT Work

OnabotulinumtoxinA is not recommended for chronic tension-type headache - it showed no statistically significant improvement in critical outcomes across 12 randomized controlled trials 1

Non-Pharmacologic Interventions

While the evidence base is limited, several non-drug approaches should be considered:

• EMG biofeedback has documented efficacy in tension-type headache 2
• Cognitive-behavioral therapy and relaxation training are most likely effective 2
• Physical therapy and acupuncture may be valuable options for frequent tension-type headache, though robust scientific evidence is lacking 2
• Exercise and massage therapy can be considered as adjunctive treatments 4

Evidence Limitations

The 2023 VA/DoD guidelines found insufficient evidence to recommend for or against biofeedback, cognitive behavioral therapy, mindfulness-based therapies, and progressive muscle relaxation when used alone 1. However, the European Federation of Neurological Societies guidelines support their use based on available data 2.

Treatment Algorithm

For episodic tension-type headache (<15 days/month):

1. Ibuprofen 400 mg or acetaminophen 1000 mg at headache onset 1
2. Limit use to <2 days per week to prevent medication-overuse headache 3
3. Consider non-pharmacologic interventions as adjuncts 2

For chronic tension-type headache (≥15 days/month):

1. Initiate amitriptyline 50-100 mg daily for prevention 1
2. Continue ibuprofen 400 mg or acetaminophen 1000 mg for breakthrough headaches 1
3. If amitriptyline is not tolerated, switch to mirtazapine or venlafaxine 2
4. Incorporate non-pharmacologic therapies (EMG biofeedback, cognitive-behavioral therapy) 2