What are the top ten medication choices for treating tension‑type (vice‑like) headache in otherwise healthy adults?

Top Medications for Tension-Type (Vice-Like) Headache

For acute tension-type headache, ibuprofen 400 mg or acetaminophen 1000 mg are the recommended first-line treatments, with ibuprofen preferred due to its superior efficacy and favorable side-effect profile. 1, 2

First-Line Acute Treatment Options

NSAIDs (Preferred)

• Ibuprofen 400 mg is the single best choice for acute tension-type headache based on equivalent efficacy to other analgesics but with a generally more favorable side-effect profile. 1, 2
• Naproxen 550-825 mg is an alternative NSAID with documented efficacy, though ibuprofen remains preferred. 3
• Ketoprofen 50-75 mg has demonstrated superiority over aspirin or paracetamol for tension-type headache episodes. 3

Acetaminophen (Alternative)

• Acetaminophen 1000 mg is recommended as an alternative first-line option, particularly for patients who cannot tolerate NSAIDs. 1
• Acetaminophen has slightly lower efficacy than NSAIDs but remains a reasonable choice for mild-to-moderate tension-type headache. 3

Second-Line Acute Treatment Options

Combination Analgesics

• Aspirin-acetaminophen-caffeine combinations are drugs of second choice, with caffeine-containing preparations showing slight superiority to single agents. 3, 4
• These combinations should be used sparingly (no more than twice weekly) to avoid progression to chronic daily headache. 3, 4

Adjunctive Medications

• Sedating antihistamines or antiemetics can potentiate the pain-relieving effects of standard analgesics when added to first-line agents. 5

Medications to Avoid for Acute Treatment

• Triptans should NOT be used for tension-type headache, as they lack efficacy for this headache type. 4
• Muscle relaxants should NOT be used for acute tension-type headache treatment. 4
• Opioids should NOT be used for tension-type headache due to lack of efficacy and high risk of medication-overuse headache. 4
• Analgesics combined with butalbital have increased risk of causing chronic daily headache and should be avoided despite their pain-relieving properties. 5

Preventive Treatment for Chronic Tension-Type Headache

First-Line Preventive

• Amitriptyline is the only medication with strong evidence for prevention of chronic tension-type headache and is recommended as the drug of first choice. 1, 6, 4
• Amitriptyline has been documented in multiple double-blind, placebo-controlled studies with an efficacy rate of 40-50%. 6, 3

Second-Line Preventive Options

• Mirtazapine and venlafaxine have documented efficacy as second-line preventive agents. 6, 4
• Gabapentin, topiramate, and tizanidine have weaker evidence but may be considered when first-line agents fail. 6

Preventive Treatment to Avoid

• Botulinum toxin injection should NOT be used for prevention of chronic tension-type headache, as guidelines recommend against this intervention. 1

Critical Frequency Limitation

• Limit all acute medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to chronic daily headache. 1, 3, 5, 4
• Patients using acute medications more than twice weekly should be transitioned to preventive therapy immediately. 5, 4

Non-Pharmacological Adjuncts

• EMG biofeedback has documented efficacy (40-50% response rate) and should be considered alongside medication. 3, 4
• Cognitive-behavioral therapy and relaxation training are most likely effective and should be offered as adjuncts. 4
• Physical therapy and acupuncture may be valuable options but lack robust scientific evidence for efficacy. 4

Treatment Algorithm

1. Start with ibuprofen 400 mg at headache onset for acute episodes. 1, 2
2. If ibuprofen is contraindicated or ineffective after 2-3 episodes, switch to acetaminophen 1000 mg. 1
3. If monotherapy fails, consider adding a sedating antihistamine or antiemetic for potentiation. 5
4. If headaches occur more than twice weekly, immediately initiate amitriptyline for prevention while limiting acute medication use. 1, 4
5. If amitriptyline fails or is not tolerated, escalate to mirtazapine or venlafaxine. 6, 4

Common Pitfalls to Avoid

• Using acute medications more than twice weekly creates a vicious cycle of medication-overuse headache—this is the single most important pitfall to avoid. 3, 5, 4
• Prescribing triptans, muscle relaxants, or opioids for tension-type headache wastes resources and exposes patients to unnecessary risks without benefit. 4
• Failing to initiate preventive therapy when acute medication frequency exceeds twice weekly allows progression to chronic daily headache. 5, 4
• Using butalbital-containing compounds or caffeine-containing preparations frequently accelerates headache chronification. 3, 5