How should I evaluate and manage a patient with stress‑related (tension‑type) headaches, including red‑flag screening, lifestyle modifications, acute NSAID therapy, and prophylactic medication options?

Management of Stress-Related (Tension-Type) Headaches

For acute tension-type headache, start with ibuprofen 400 mg or acetaminophen 1000 mg, and for chronic tension-type headache requiring prevention, use amitriptyline 30-150 mg/day as first-line prophylaxis. 1

Red-Flag Screening

Before diagnosing tension-type headache, systematically exclude secondary causes by screening for:

• Thunderclap onset (sudden, severe "worst headache of life") 1
• Progressive worsening over days to weeks 1
• New-onset headache after age 50 1
• Headache awakening patient from sleep 1
• Headache worsened by Valsalva maneuver (coughing, straining) 1
• Fever with neck stiffness 1
• Focal neurological deficits (weakness, sensory changes, visual field cuts) 1
• Recent head trauma 1
• Altered mental status or impaired memory 1

Neuroimaging (CT or MRI) is indicated only when red-flag features are present; patients with normal neurologic examination and typical tension-type headache features do not require imaging. 1

Diagnostic Criteria for Tension-Type Headache

Tension-type headache requires at least two of the following features:

• Bilateral location (not unilateral) 1
• Pressing or tightening quality (non-pulsatile) 1, 2
• Mild to moderate intensity (not severe) 1
• No aggravation with routine physical activity 1

Absence of migraine features distinguishes tension-type headache from migraine:

• No nausea or vomiting (anorexia may be present) 1
• No photophobia AND phonophobia together (one or the other may occur, but not both) 1
• No throbbing quality 1

Acute Treatment Algorithm

First-Line Acute Therapy

Ibuprofen 400 mg or acetaminophen 1000 mg are the recommended first-line agents for episodic tension-type headache. 1, 3, 4

• Ibuprofen 400-800 mg demonstrates superior efficacy compared to aspirin or acetaminophen alone 3, 4
• Acetaminophen 1000 mg provides statistically significant pain relief with a number-needed-to-treat of 22 5
• Lower doses of acetaminophen (500-650 mg) lack demonstrated efficacy and should not be used 5

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, 2, 3

• Use of analgesics ≥15 days per month transforms episodic headache into chronic daily headache 1, 2
• If acute treatment is needed more than twice weekly, initiate prophylactic therapy immediately 1

Medications to Avoid

Do not use triptans for tension-type headache, as they lack efficacy for this indication and carry unnecessary cardiovascular risk. 3

Avoid butalbital-containing compounds and opioids because they have questionable efficacy, high risk of medication-overuse headache, potential for dependency, and poor long-term outcomes. 1, 5, 2

Prophylactic Treatment

Indications for Preventive Therapy

Initiate prophylactic treatment when:

• Headaches occur ≥15 days per month (chronic tension-type headache) 1, 6
• Acute medication use exceeds 2 days per week 1
• Significant disability despite optimized acute treatment 1
• Contraindications to or failure of acute therapies 1

First-Line Prophylactic Agent

Amitriptyline 30-150 mg/day is the drug of first choice for prophylactic treatment of chronic tension-type headache, supported by multiple double-blind, placebo-controlled trials with an efficacy rate of 40-50%. 1, 6, 3, 4

• Start at 10-25 mg at bedtime and titrate upward every 1-2 weeks based on response and tolerability 6, 3
• Efficacy requires 2-3 months of treatment before determining success or failure 1
• Amitriptyline is particularly beneficial for patients with comorbid depression, anxiety, or sleep disturbances 5

Second-Line Prophylactic Options

If amitriptyline is contraindicated or ineffective:

• Mirtazapine or venlafaxine are second-choice antidepressants with documented efficacy 6, 3
• Gabapentin, topiramate, and tizanidine have weaker evidence but may be considered 6, 3

Prophylactic Agents to Avoid

Do not use botulinum toxin (Botox) for tension-type headache prevention, as it lacks efficacy for this indication (it is FDA-approved only for chronic migraine, not tension-type headache). 1

Lifestyle Modifications and Non-Pharmacologic Interventions

Evidence-Based Behavioral Interventions

Physical therapy or aerobic exercise can be used in management of tension-type headache, though the evidence base is limited. 1

EMG biofeedback has documented efficacy in tension-type headache with an effect size comparable to amitriptyline (40-50% response rate). 3, 4

Cognitive-behavioral therapy and relaxation training are most likely effective, though robust scientific evidence is limited. 3, 4

Acupuncture may be a valuable option for patients with frequent tension-type headache, but there is no robust scientific evidence for efficacy. 3, 4

Trigger Identification and Management

• Maintain a headache diary (paper or smartphone-based) to identify modifiable triggers such as stress, poor sleep, caffeine overuse, and postural factors 1, 5
• Systematic tracking improves accuracy of attack-frequency reporting and helps recognize patterns 5
• Address modifiable risk factors including stress, sleep deprivation, excessive caffeine intake, and psychiatric comorbidities (depression, anxiety) 5

Common Pitfalls to Avoid

Do not allow patients to increase acute medication frequency in response to worsening headaches; instead, transition to prophylactic therapy while maintaining the 2-days-per-week limit for acute treatment. 1, 7, 5

Do not prescribe combination analgesics containing caffeine for frequent use, as they carry increased risk of medication-overuse headache despite slightly superior acute efficacy. 3, 4

Do not delay preventive therapy while trialing multiple acute strategies, as this undermines timely control of chronic tension-type headache. 1, 5

Avoid unnecessary neuroimaging in patients with typical tension-type headache features and normal neurologic examination, as this increases cost, radiation exposure, and risk of incidental findings leading to further unwarranted testing. 1, 5