What acute and preventive medication regimen should I use next for a 24-year-old woman with chronic pressure-type headaches occurring about every two weeks, worsening throughout the day, partially relieved by ibuprofen and possibly having migraine features?

Management of Chronic Episodic Tension-Type Headache with Possible Migraine Features

Start with ibuprofen 400–800 mg at headache onset, limit use to no more than 2 days per week, and initiate preventive therapy with amitriptyline 30–150 mg/day immediately because this patient already requires acute treatment twice monthly and has mixed tension-type and possible migraine features. 1, 2

Acute Treatment Strategy

First-Line Acute Medication

• Ibuprofen 400–800 mg is the most effective acute treatment for tension-type headache, superior to aspirin or acetaminophen, and should be taken as early as possible during the attack. 3, 4
• The NNT for ibuprofen 400 mg to achieve pain freedom at 2 hours is 14, with a global evaluation of 'very good' or 'excellent' having an NNT of 5.9. 4
• Naproxen 500–825 mg is an alternative NSAID with similar efficacy if ibuprofen is not tolerated. 2, 3

Critical Frequency Limitation

• Restrict all acute medication use to ≤ 2 days per week (approximately 10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 2, 5
• This patient's current pattern of twice-monthly headaches already places her at the threshold where preventive therapy is indicated. 1, 2

When to Escalate Acute Treatment

• If ibuprofen fails after 2–3 headache episodes, consider adding a triptan (sumatriptan 50–100 mg) if migraine features become more prominent (photophobia, phonophobia, nausea, or unilateral throbbing pain). 2, 6
• Combination therapy with sumatriptan 50–100 mg PLUS naproxen 500 mg is superior to either agent alone for moderate-to-severe attacks. 2

Preventive Therapy—Start Now

Why Preventive Therapy Is Indicated

• This patient meets criteria for preventive therapy: ≥ 2 attacks per month producing disability lasting ≥ 3 days, and the pattern suggests mixed tension-type and possible migraine features. 1, 2
• Preventive therapy reduces attack frequency by ≥ 50% and restores responsiveness to acute treatments. 2

First-Line Preventive Medication

• Amitriptyline 30–150 mg/day at bedtime is the single best choice for this patient because it has consistent evidence for efficacy in both migraine prevention and is superior for patients with mixed migraine and tension-type headache. 1
• Start at 10–25 mg at bedtime and titrate upward by 10–25 mg every 1–2 weeks until therapeutic effect is achieved or side effects limit further increase. 1
• Common side effects include drowsiness, weight gain, and anticholinergic symptoms (dry mouth, constipation), which are usually well tolerated and seldom cause discontinuation. 1
• Efficacy requires 2–3 months of treatment at therapeutic dose before determining success or failure. 2

Alternative Preventive Options

• Beta-blockers without intrinsic sympathomimetic activity (propranolol 80–240 mg/day, timolol 20–30 mg/day, metoprolol, atenolol, or nadolol) are effective first-line alternatives if amitriptyline is not tolerated. 1
• Propranolol is more efficacious in patients with migraine alone, while amitriptyline is superior for mixed headache types. 1
• Common beta-blocker side effects include fatigue, depression, nausea, dizziness, and insomnia. 1

Diagnostic Clarification

Distinguishing Tension-Type from Migraine

• Pressure-type pain worsening throughout the day is classic for tension-type headache. 3, 4
• If photophobia, phonophobia, nausea, or unilateral throbbing pain develop, the diagnosis shifts toward migraine or mixed headache disorder. 2
• A headache diary (paper or smartphone app) is essential to track attack frequency, severity, associated symptoms, and medication use—this will guide whether to escalate to triptan therapy. 2

Critical Pitfalls to Avoid

Do Not Allow Frequent Acute Medication Use

• Never permit this patient to increase ibuprofen frequency beyond 2 days per week in response to increasing headache frequency—this creates a vicious cycle of medication-overuse headache. 2, 5
• If headaches increase in frequency despite preventive therapy, reassess for medication overuse before escalating treatment. 2

Avoid Ineffective or Harmful Medications

• Do not prescribe opioids (codeine, hydrocodone, oxycodone) or butalbital-containing compounds—they have limited efficacy, cause dependency, trigger rebound headaches, and worsen long-term outcomes. 2
• Caffeine-containing preparations should not be taken frequently to avoid headache chronification. 3

Follow-Up and Monitoring

Timeline for Reassessment

• Reassess at 4–6 weeks to evaluate adherence, side effects, and early response to amitriptyline. 1
• Full efficacy assessment requires 2–3 months of preventive therapy at therapeutic dose. 2
• If amitriptyline fails after adequate trial (≥ 2–3 months at maximum tolerated dose), switch to a beta-blocker or consider topiramate/divalproex sodium. 1

Goals of Treatment

• Reduce headache frequency by ≥ 50%. 2
• Restore responsiveness to acute treatments. 2
• Improve quality of life and reduce disability. 1, 2