What is the recommended treatment for tension‑type headache in an otherwise healthy adult?

Treatment of Tension-Type Headache

Acute Treatment

For acute tension-type headache, start with ibuprofen 400 mg or acetaminophen 1000 mg at the onset of headache. 1, 2

• Both medications demonstrate statistically significant improvement in pain-free response at 2 hours 1
• Take medication early in the headache episode for maximum effectiveness 1
• If initial treatment provides inadequate relief, consider combination analgesics containing caffeine or 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 increases risk of progression to chronic daily headache 1
• Avoid butalbital-containing compounds due to high risk of dependence and medication overuse headache 1
• Avoid opioids entirely for tension-type headache due to risk of dependence and medication overuse headache 1, 2
• Triptans and muscle relaxants should not be used for tension-type headache 3

Preventive Treatment for Chronic Tension-Type Headache

Amitriptyline is the first-line drug for prevention of chronic tension-type headache. 1, 2, 3

When to Initiate Preventive Treatment

Consider prophylactic treatment when: 1

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

Amitriptyline Dosing Algorithm

• Start at 10-25 mg at bedtime 2
• Gradually titrate up to 50-100 mg as needed and tolerated 1, 2
• Both 50 mg and 100 mg doses significantly reduce monthly headache days 1
• Monitor closely for anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities 1

Second-Line Preventive Options

If amitriptyline fails or is not tolerated: 1, 2

• Mirtazapine (second choice)
• Venlafaxine (second choice)
• Valproate may be considered as an alternative with appropriate monitoring 4

Medications NOT Recommended for Prevention

• Botulinum toxin injections are specifically not recommended for chronic tension-type headache 4
• Gabapentin is not recommended based on lack of efficacy evidence and potential for misuse 4

Non-Pharmacological Approaches

Physical therapy and aerobic exercise are recommended as adjunctive management options for tension-type headache. 5, 1, 2

Evidence-Based Non-Pharmacological Options

• Physical therapy has moderate evidence for management of tension-type headache 5, 4
• Aerobic exercise or progressive strength training for prevention 5, 2, 4
• EMG biofeedback has documented effect in tension-type headache 3
• Cognitive-behavioral therapy and relaxation training are most likely effective 3
• Acupuncture may be valuable for patients with frequent tension-type headache, though evidence quality is mixed 6, 3

Lifestyle Modifications

Important adjunctive measures include: 2

• Regular meals
• Adequate hydration
• Sleep hygiene improvement
• Stress management techniques

Procedural Interventions

• Greater occipital nerve blocks are suggested for short-term treatment of headache with weak evidence 5, 4
• Consider only after optimizing pharmacological and non-pharmacological approaches 4

Treatment Algorithm for Chronic Tension-Type Headache

When standard preventive treatment with amitriptyline has failed: 4

1. Confirm diagnosis and rule out medication overuse headache - ensure patient is not overusing acute medications (>2 days/week)
2. Optimize abortive therapy - ensure proper dosing of ibuprofen 400 mg or acetaminophen 1000 mg for breakthrough episodes
3. Try alternative preventive medication - mirtazapine or venlafaxine as second-line options
4. Consider procedural intervention - greater occipital nerve block for short-term relief
5. Evaluate for comorbidities - psychiatric disorders and sleep disturbances may affect treatment response

Common Pitfalls to Avoid

• Never allow frequent use of acute medications - this is the most common cause of treatment failure and progression to chronic daily headache 1, 2
• Do not use triptans, muscle relaxants, or opioids for tension-type headache 3
• Avoid butalbital-containing compounds entirely 1
• Be vigilant about anticholinergic side effects when using amitriptyline, particularly in elderly patients 1
• Regular assessment of treatment effectiveness and adjustment of therapy as needed is essential 2