First-Line Treatment for Tension-Type Headache
For acute tension-type headache in adults, ibuprofen 400 mg or acetaminophen 1000 mg should be taken at headache onset, with use strictly limited to no more than 2 days per week to prevent medication-overuse headache. 1
Acute Treatment Algorithm
First-Line Options
- Ibuprofen 400 mg is recommended as the primary acute treatment for episodic tension-type headache, taken at the earliest sign of pain. 1, 2
- Acetaminophen 1000 mg is the alternative first-line option when NSAIDs are contraindicated or not tolerated. 1, 2
- Simple analgesics and NSAIDs are the only recommended acute medications for tension-type headache. 3, 2, 4
Critical Frequency Limitation
- All acute medications must be limited to ≤2 days per week (≤10 days per month) to prevent progression to chronic daily headache and medication-overuse headache. 1, 4
- Using pain relievers more than twice weekly places patients at significant risk for developing chronic daily headache. 4
Medications to Avoid
- Triptans should never be used for tension-type headache, as they lack efficacy for this condition. 3, 2
- Muscle relaxants are not recommended for acute tension-type headache treatment. 3, 2
- Opioids should not be used due to questionable efficacy, high dependence risk, and propensity to cause medication-overuse headache. 3, 2
- Butalbital-containing compounds carry increased risk of chronic daily headache and should be avoided. 4
When to Escalate to Preventive Therapy
Indications for Prevention
- Initiate prophylactic treatment when patients experience ≥2 disabling attacks per month producing disability lasting ≥3 days. 5
- Prevention is indicated when acute medication use exceeds 2 days per week, creating risk for medication-overuse headache. 5
- Consider prevention when quality of life is significantly impaired between attacks. 5
First-Line Preventive Treatment
- Amitriptyline is the drug of first choice for prophylaxis of chronic tension-type headache, with the strongest evidence base from multiple double-blind, placebo-controlled trials. 5, 3, 6, 2, 7, 4
- Aerobic exercise or progressive strength training should be recommended as adjunctive non-pharmacological interventions. 5
Second-Line Preventive Options
- Mirtazapine or venlafaxine are second-choice drugs when amitriptyline is ineffective or not tolerated. 5, 3, 6, 2
- Physiotherapy may be a valuable option for patients with frequent tension-type headache. 5, 2
Common Pitfalls to Avoid
- Do not prescribe combination analgesics containing caffeine as first-line therapy; these are drugs of second choice only. 3, 2
- Never use botulinum toxin injections for tension-type headache prevention—this is explicitly contraindicated and differs from chronic migraine where it is effective. 1, 5
- Do not allow patients to self-escalate acute medication frequency when headaches become more frequent; instead, transition immediately to preventive therapy. 5, 4
- Patients cannot reliably report headache frequency without documentation, so require a headache diary to track frequency, severity, and medication use before making treatment decisions. 5