What is the appropriate management for tension-type headache?

Management of Tension-Type Headache

For acute tension-type headache, use ibuprofen 400 mg or acetaminophen 1000 mg, and for prevention of chronic tension-type headache, prescribe amitriptyline 50-100 mg daily. 1

Acute Treatment

First-Line Pharmacotherapy

• Ibuprofen 400 mg or acetaminophen 1000 mg are the recommended acute treatments, both demonstrating statistically significant pain-free response at 2 hours. 1
• Acetaminophen doses below 1000 mg (such as 500-650 mg) are ineffective and should not be used. 1
• Simple analgesics and NSAIDs are considered first-line medications for episodic tension-type headache. 2

Critical Limitation Strategy

• Limit acute medication use to maximum 2 days per week or 10 days per month to prevent medication overuse headache, which can transform episodic tension-type headache into chronic daily headache. 1
• Combination analgesics containing caffeine are second-choice options only. 2

Medications to Avoid

• Do not use triptans, muscle relaxants, or opioids for tension-type headache—these are ineffective and carry significant risks. 2

Preventive Treatment

When to Initiate Prevention

Preventive therapy is indicated for:

• Chronic tension-type headache (≥15 days per month)
• Frequent episodic tension-type headache
• Patients at risk of medication overuse headache
• Those unable to tolerate effective acute treatment 3

First-Line Preventive Agent

• Amitriptyline 50-100 mg daily is the recommended preventive treatment, with both doses significantly reducing monthly headache days. 1
• Start at lower doses (typically 10-25 mg at bedtime) and titrate upward based on response and tolerability. 4

Important Safety Considerations for Amitriptyline

• Monitor closely for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities. 1
• Be aware of overdose potential—this is a critical safety concern. 1
• Common side effects include dry mouth, constipation, urinary retention, and sedation. 2

Second-Line Preventive Options

• Mirtazapine or venlafaxine are alternative preventive agents when amitriptyline is contraindicated or not tolerated. 4, 2
• These medications have documented efficacy but are considered second-choice options. 2

Ineffective Preventive Treatment

• Do not use botulinum toxin (onabotulinumtoxinA) for chronic tension-type headache—systematic review of 12 RCTs showed no statistically significant improvement in critical outcomes. 1

Non-Pharmacological Management

Lifestyle Modifications

• Ensure regular meals—missed meals are a documented trigger for tension-type headache. 5, 6
• Implement adequate hydration and regular sleep schedule. 1
• Limit caffeine intake to prevent rebound headaches. 1

Evidence-Based Non-Drug Therapies

• EMG biofeedback has documented effectiveness for tension-type headache. 2
• Cognitive-behavioral therapy and relaxation training are likely effective. 2
• Physical therapy and acupuncture may be valuable options, though robust scientific evidence is limited. 2

Diagnostic Considerations

Clinical Features to Confirm Diagnosis

• Bilateral, pressing or tightening (non-pulsatile) pain of mild to moderate intensity. 5, 7
• Not aggravated by routine physical activity. 5
• Lacks nausea/vomiting (though anorexia may be present), and typically does not have both photophobia and phonophobia. 5

Red Flags Requiring Further Evaluation

• Sudden onset ("thunderclap" headache)
• Fever with headache
• Focal neurological symptoms
• New onset after age 50
• Progressive worsening pattern 5

Routine neuroimaging is not indicated for typical tension-type headache without concerning features on history or examination. 5

Key Differential Diagnoses

• Migraine: unilateral, throbbing, moderate-severe intensity, worsens with activity, associated with nausea/vomiting and photophobia/phonophobia. 5
• Cluster headache: strictly unilateral, severe pain lasting 15-180 minutes with ipsilateral autonomic symptoms (lacrimation, nasal congestion, ptosis). 5

Treatment Algorithm Summary

Step 1: Acute episodes → Ibuprofen 400 mg or acetaminophen 1000 mg 1

Step 2: If headaches occur >2 days/week or >10 days/month → Initiate preventive therapy with amitriptyline 50-100 mg daily 1

Step 3: If amitriptyline contraindicated/not tolerated → Switch to mirtazapine or venlafaxine 2

Step 4: Throughout treatment → Implement lifestyle modifications and consider EMG biofeedback or cognitive-behavioral therapy 2