Management of Tension-Type Headache

Acute Treatment Strategy

The American College of Physicians recommends using NSAIDs, such as ibuprofen 400-800mg, as first-line treatment for acute tension-type headache, with acetaminophen 1000mg as an alternative when NSAIDs are contraindicated 1
The European Neurology Society suggests limiting simple analgesics to fewer than 15 days per month to prevent medication overuse headache, which significantly worsens outcomes and prevents effectiveness of preventive treatments 2, 3, 4, 5

The American Academy of Neurology recommends amitriptyline as the first-choice preventive medication for chronic tension-type headache, with a documented efficacy rate of approximately 40-50%, and suggests starting slowly and titrating to therapeutic tolerated dose over 3 months for adequate therapeutic trial 2, 3, 4
The European Neurology Society suggests considering mirtazapine or venlafaxine as alternative preventive medications, with venlafaxine being weight neutral and helpful with comorbid depression symptoms 2, 3, 4

The American College of Sports Medicine recommends physical therapy and aerobic exercise as non-pharmacologic interventions for the management and prevention of tension-type headache 1, 6

The American Heart Association recommends limiting caffeine intake, ensuring regular meals and adequate hydration, maintaining consistent sleep schedule and good sleep hygiene, and regular exercise program to help manage tension-type headache 2, 3, 4, 7

The American Academy of Neurology suggests a treatment algorithm that starts with NSAIDs for acute episodes, and initiates amitriptyline as first-line preventive medication for frequent or chronic tension-type headache, with addition of stress management therapy and physical therapy or aerobic exercise program for optimal outcomes 1, 2, 3, 4, 7, 6

Physical therapy delivered by a physical therapist is beneficial for chronic tension-type headache prevention, using combination techniques such as thermal methods, trigger point massage, and mobilization/manipulation, as recommended by the American College of Physicians 8
Aerobic exercise or progressive strength training is recommended for prevention, with a frequency of 2-3 times per week for 30-60 minutes, as suggested by the American College of Sports Medicine 8
Upper-body progressive strength training is typically done 3 times a week for 30 minutes, supervised, as recommended by the American College of Sports Medicine 8

Spinal manipulation was associated with moderate improvement in short-term pain and small improvement in function versus usual care, though evidence has serious methodological limitations, according to the Centers for Disease Control and Prevention 9

The American Academy of Family Physicians recommends initiating preventive therapy when headaches occur more than twice per week 10