What is the recommended acute and preventive management for tension‑type headache in an adult?

Management of Tension-Type Headache in Adults

For acute tension-type headache, use ibuprofen 400 mg or acetaminophen 1000 mg at headache onset, and for chronic tension-type headache requiring prevention, start amitriptyline 10-25 mg at bedtime, titrating to 50-100 mg as tolerated. 1, 2

Acute Treatment

First-Line Medications

• Ibuprofen 400 mg is the primary recommendation for acute tension-type headache, demonstrating statistically significant pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg is equally effective as an alternative first-line option, also showing significant improvement in pain-free response at 2 hours 1, 2
• Take medication early in the headache episode for maximum effectiveness 1

Combination Therapy for Inadequate Response

• If initial treatment fails, consider combination analgesics containing caffeine or switch to alternative NSAIDs such as naproxen sodium 550 mg 1
• For severe attacks with nausea, add an antiemetic medication to improve treatment outcomes 1

Critical Medication Overuse Warning

• Limit acute medication use to no more than 2 days per week to prevent medication overuse headache 2
• Using acute treatments more than twice weekly significantly increases risk of progression to chronic daily headache 1
• Avoid butalbital-containing compounds entirely due to high risk of dependence and medication overuse headache 1
• Never use opioids for tension-type headache due to dependence risk and medication overuse headache 1, 2

Preventive Treatment

Indications for Prophylaxis

Consider preventive therapy when patients have:

• Two or more attacks per month producing disability lasting 3 or more days 1
• Contraindication to or failure of acute treatments 1
• Use of abortive medication more than twice per week (risk of medication overuse headache) 1

First-Line Preventive Medication

• Amitriptyline is the drug of first choice for chronic tension-type headache prevention, with doses of 50-100 mg significantly reducing monthly headache days 1, 2
• Start at 10-25 mg at bedtime, then gradually titrate up to 50-100 mg as needed and tolerated 2
• Monitor closely for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1, 2

Alternative Preventive Options

• Venlafaxine or mirtazapine are second-line options if amitriptyline is not tolerated 3, 4
• Valproate may be considered as an alternative with appropriate monitoring 5
• Memantine may be worth considering for tension-type headache that has failed standard therapies 5

Medications NOT Recommended for Prevention

• Gabapentin is specifically not recommended based on lack of efficacy evidence and potential for misuse 5
• Botulinum toxin injections are not recommended for chronic tension-type headache prevention 5

Non-Pharmacological Approaches

Evidence-Based Options

• Physical therapy and aerobic exercise are recommended as adjunctive management options for both acute and preventive management 1, 2, 5
• EMG biofeedback has documented effectiveness in tension-type headache 3
• Cognitive-behavioral therapy and relaxation training are most likely effective 3
• Acupuncture may be valuable but lacks robust scientific evidence 3

Lifestyle Modifications

• Encourage regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques 2
• Help patients identify and avoid trigger factors 6

Treatment Algorithm

For Episodic Tension-Type Headache:

1. Use ibuprofen 400 mg or acetaminophen 1000 mg at onset 1, 2
2. If inadequate relief, try combination analgesics with caffeine or alternative NSAID 1
3. Add antiemetic if nausea present 1
4. Strictly limit use to ≤2 days per week 2

For Chronic Tension-Type Headache:

1. Confirm diagnosis and rule out medication overuse headache (>4 days/week of acute medication use) 5
2. Optimize abortive therapy with proper dosing of ibuprofen 400 mg or acetaminophen 1000 mg 5
3. Start amitriptyline 10-25 mg at bedtime, gradually increase to effective dose (typically 50-100 mg) 2
4. Monitor for anticholinergic side effects and adjust accordingly 2
5. If amitriptyline fails or is not tolerated, try venlafaxine or mirtazapine 3
6. Consider greater occipital nerve blocks for short-term relief 5
7. Evaluate for comorbidities including psychiatric disorders and sleep disturbances that may affect treatment response 5

Common Pitfalls to Avoid

• Never allow patients to use acute medications more than 2 days per week - this is the most critical factor in preventing transformation to chronic daily headache 1, 2
• Do not prescribe butalbital-containing compounds or opioids - these have unacceptably high risks of dependence and medication overuse headache 1, 2
• Do not use triptans for tension-type headache - they are ineffective and inappropriate for this condition 3
• When starting amitriptyline, begin with low doses (10-25 mg) and titrate slowly to minimize anticholinergic side effects, particularly in elderly patients 2
• Assess treatment response regularly and adjust therapy if inadequate pain relief is achieved 1