What is the recommended acute and preventive treatment for a typical adult with primary tension‑type headache?

Treatment of Tension-Type Headache

For acute treatment of 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 with gradual titration to 50-100 mg as needed. 1, 2

Acute Treatment Approach

First-line acute therapy:

• Ibuprofen 400 mg is the preferred initial option, showing statistically significant improvement in pain-free response at 2 hours 1, 2
• Acetaminophen 1000 mg is equally effective as an alternative first-line choice 1, 2
• Medications must be taken early in the headache episode for maximum effectiveness 2

Second-line options if inadequate response:

• Combination analgesics containing caffeine can be considered 1, 2, 3
• Alternative NSAIDs such as naproxen sodium 550 mg may be tried 2
• For severe attacks with nausea, add an antiemetic medication 2

Critical medication overuse warning:

• Limit acute medication use to no more than 2 days per week to prevent medication overuse headache 1, 2
• Avoid butalbital-containing compounds due to high risk of dependence and medication overuse headache 2
• Never use opioids for tension-type headache due to dependence risk and medication overuse potential 1, 2
• Triptans and muscle relaxants should not be used for tension-type headache 3

Preventive Treatment Strategy

Indications for preventive therapy:

• Two or more attacks per month producing disability lasting 3 or more days 1, 2
• Contraindication to or failure of acute treatments 1, 2
• Use of abortive medication more than twice per week 1, 2

Pharmacologic prevention:

• Amitriptyline is the first-choice preventive medication with consistent evidence for efficacy 1, 2, 3
• Start at 10-25 mg at bedtime, gradually titrate to 50-100 mg as needed and tolerated 1, 2
• Monitor for anticholinergic adverse effects (dry mouth, constipation, urinary retention, drowsiness, weight gain), especially in older patients and those with cardiac comorbidities 2
• Second-line preventive options include mirtazapine and venlafaxine if amitriptyline is not tolerated or effective 4, 5, 3

The evidence for amitriptyline in chronic tension-type headache is notably stronger than for migraine prevention, where one trial suggested amitriptyline was superior for patients with mixed migraine and tension-type headache 6. This makes amitriptyline particularly appropriate for this indication.

Non-Pharmacological Management

Evidence-based non-drug approaches:

• Physical therapy is recommended as adjunctive management with moderate-quality evidence for reducing headache frequency and severity 1, 2
• Aerobic exercise or progressive strength-training programs show beneficial effects on headache occurrence 2
• EMG biofeedback has documented effectiveness in tension-type headache 3
• Cognitive-behavioral therapy and relaxation training are most likely effective 3
• Acupuncture may be a valuable option for frequent tension-type headache 3

Lifestyle modifications:

• Regular meals, adequate hydration, sleep hygiene improvement, and stress management techniques 1

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, 2
3. Ensure use is limited to ≤2 days per week 1
4. Add physical therapy and aerobic exercise as adjunctive measures 1, 2

For chronic tension-type headache:

1. Initiate amitriptyline 10-25 mg at bedtime 1, 2
2. Gradually increase to effective dose (typically 50-100 mg) 1, 2
3. Monitor for anticholinergic side effects and adjust accordingly 2
4. Continue acute treatment as above, but ensure not overusing medications 1
5. Incorporate physical therapy and aerobic exercise 1, 2
6. If amitriptyline fails or is not tolerated, consider mirtazapine or venlafaxine 4, 3

Common Pitfalls to Avoid

• Do not prescribe opioids or butalbital compounds - these carry high dependence risk and worsen headache patterns 1, 2
• Do not allow frequent acute medication use - using treatments more than twice weekly increases risk of progression to chronic daily headache 2
• Do not use triptans - these are ineffective for tension-type headache and waste resources 3
• Be vigilant about secondary headache disorders in older adults, as many conditions can mimic tension-type headache presentation 7