What is the first‑line oral treatment for an adult with episodic tension‑type headache?

First-Line Oral Treatment for Episodic Tension-Type Headache

Ibuprofen 400 mg or aspirin 1000 mg are the recommended first-line oral treatments for adults with episodic tension-type headache, based on their superior efficacy, safety profile, and cost-effectiveness. 1

Evidence-Based Treatment Algorithm

First-Line Options

• Ibuprofen 400 mg is the preferred initial choice, with a number needed to treat (NNT) of approximately 7-8 for achieving pain-free status at 2 hours in adults with moderate to severe tension-type headache. 2
• Aspirin 1000 mg serves as an equally effective alternative, with an NNT of 5.7 for patient satisfaction and 6.0 for preventing rescue medication use. 3
• Both medications should be taken at the onset of headache when pain is still moderate, as early treatment improves efficacy. 1

Second-Line Option

• Paracetamol (acetaminophen) 1000 mg is reserved for patients who cannot tolerate NSAIDs, though it demonstrates inferior efficacy with an NNT of 22 for being pain-free at 2 hours—substantially higher than ibuprofen or aspirin. 4
• Lower doses of paracetamol (500-650 mg) have not shown statistically significant benefit over placebo and should not be used. 4

Critical Frequency Limitation

• Limit all acute tension-type headache 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. 5
• If headaches occur more than twice weekly, initiate preventive therapy rather than increasing acute medication frequency. 5

Medications to Avoid

• Triptans have no role in tension-type headache treatment and should not be prescribed. 5
• Muscle relaxants and opioids should not be used for tension-type headache due to lack of efficacy and risk of dependency. 5
• Combination analgesics containing caffeine are second-choice drugs only after simple analgesics fail. 5

Non-Pharmacological Adjuncts

• Electromyographic (EMG) biofeedback has documented efficacy and should be offered alongside pharmacological treatment. 5
• Physiotherapy and muscle relaxation therapy may provide additional benefit, particularly for patients with frequent episodic tension-type headache. 5
• These non-pharmacological approaches address the peripheral myofascial nociceptor activation that triggers acute tension-type headache episodes. 1

Common Pitfall to Avoid

• Do not prescribe combination analgesics or stronger agents as first-line therapy—the evidence clearly supports starting with simple NSAIDs at adequate doses (ibuprofen 400 mg or aspirin 1000 mg), not lower doses or weaker alternatives. 1
• Avoid the temptation to increase medication frequency when headaches persist; instead, transition to preventive therapy to break the cycle. 5