Treatment of Tension Headaches and Musculoskeletal Strains

Non-Pharmacological Interventions

Physical therapy is recommended as an effective treatment for tension headaches and musculoskeletal strains by the CDC and VA/DoD guidelines 1
Regular aerobic exercises or progressive strength training can help prevent tension headaches 2
Stress management techniques, such as yoga and mindfulness, are recommended for tension-type headache management 3
Regular meals and adequate hydration are essential for maintaining consistent eating schedule and hydration, and may help in headache management 3
Sleep hygiene optimization, including establishing regular sleep patterns, is recommended for tension-type headache management 3
Resting in a dark, quiet room, adequate hydration, stress management techniques, and sleep hygiene optimization are recommended as non-pharmacological approaches to manage headaches 4, 2
Tracking headache patterns, including frequency, severity, duration, and response to treatment, and identifying and avoiding potential triggers (alcohol, caffeine, certain foods, stress, fatigue, etc.) are recommended to help manage tension-type headaches 5

Acetaminophen (1000 mg) is recommended as a first-line acute treatment for tension-type headaches, providing significant pain relief at 2 hours, by the American College of Physicians 2, 6
Ibuprofen (400 mg) is also recommended as a first-line acute treatment for tension-type headaches, providing significant pain relief at 2 hours, by the American College of Physicians and VA/DoD guidelines 2, 6
NSAIDs, such as aspirin, diclofenac, and naproxen, are effective options for tension headache, according to the Annals of Internal Medicine guidelines and supported by the VA/DoD guidelines recommending ibuprofen as a first-line treatment 6, 2
Amitriptyline (50-100 mg daily) is recommended for prevention in chronic or frequent cases, significantly reducing monthly headache days, by the American College of Physicians 2
Botulinum toxin injections can be helpful in cases of pronounced muscle hypertonia in the shoulders 7
Opioid analgesics, such as tilidine, should be avoided due to the risk of medication-induced headaches and addiction 1
Triptans, ergotamine derivatives, and NSAIDs (including aspirin) are contraindicated in patients with a history of CVA due to vasoconstrictive effects or increased bleeding risk, and lasmiditan is not recommended due to its adverse effect profile and driving restrictions 2, 8

Overhead pull exercises for the shoulder are not recommended 7
Suprascapular nerve block can be considered for therapy-resistant shoulder pain 7
Aerobic exercise or progressive strength training is recommended for prevention, with a weak recommendation 2
Physical therapy is recommended for management of tension-type headache, although the recommendation is weak 2

Medication overuse headache occurs when analgesics are used more than twice weekly, and frequency of use should be monitored carefully, as recommended by the American Academy of Family Physicians and the Annals of Internal Medicine guidelines 5, 6
Limiting use of acute medications to no more than twice weekly is recommended to prevent medication overuse headache, by the American Academy of Family Physicians 5, 4
Considering preventive therapy if headaches occur more than twice weekly is recommended, by the American Academy of Family Physicians 5, 4

Neuroimaging should be considered to rule out recurrent CVA if headaches have atypical features or are accompanied by new neurological symptoms, by the American Academy of Family Physicians 4
Considering neuroimaging only if headaches have atypical features, are accompanied by new neurological symptoms, or if there are worrisome findings on examination is recommended, by the American Academy of Family Physicians 5