Treatment of Tension Type Headache

Acute Treatment

• The American College of Physicians recommends ibuprofen 400 mg for short-term treatment of tension-type headache, demonstrating statistically significant improvement in pain-free response at 2 hours 1, 2
• The American College of Physicians suggests acetaminophen 1000 mg as an equally effective option for acute treatment, showing significant improvement in pain-free response at 2 hours 1, 2

Preventive Treatment

• The American College of Physicians recommends amitriptyline at 50 mg and 100 mg for preventive treatment of chronic tension-type headache, significantly reducing monthly headache days in patients with chronic tension-type headache 1, 2
• The American College of Physicians advises being aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities, when using amitriptyline 1, 2

Non-Pharmacological Approaches

• The American College of Physicians suggests physical therapy and aerobic exercise as management options for tension-type headache 3
• The American College of Physicians notes that evidence for non-pharmacological interventions is generally of lower quality than for medications 4, 1

Treatment Algorithm

• For acute episodes, the American College of Physicians recommends starting with ibuprofen 400 mg or acetaminophen 1000 mg at onset of headache 1, 2
• For chronic tension-type headache, the American College of Physicians suggests considering prophylactic treatment with amitriptyline, monitoring for anticholinergic side effects and adjusting dosing accordingly 1, 2

Treatment of Tension Headache

Medication Timing

• Medications should be taken early in the headache episode for maximum effectiveness 5
• Overuse of acute medications (>2 days/week) can lead to medication overuse headache, worsening the overall condition 5

Acute Treatment of Tension-Type Headache

Treatment Approach

• For severe attacks with nausea, consider adding an antiemetic medication, as recommended by the American College of Physicians, to improve treatment outcomes 6
• Opioids should be avoided for tension-type headache due to risk of dependence and medication overuse headache, as advised by the American Academy of Family Physicians 7
• For inadequate response to initial treatment, consider combination therapy with caffeine-containing preparations or try alternative NSAID, such as naproxen sodium 550 mg, as suggested by the American Academy of Family Physicians 7

Monitoring and Adjustment

• Assess response to therapy and adjust treatment if inadequate pain relief is achieved, as recommended by the American College of Physicians, to ensure optimal treatment outcomes 6

Treatment of Chronic Tension-Type Headache

Initiation of Preventive Treatment

• The American College of Physicians recommends considering prophylactic treatment when patients experience two or more attacks per month producing disability lasting 3 or more days, contraindication to or failure of acute treatments, or use of abortive medication more than twice per week 8

Preventive Treatment Outcomes

• No cited facts are available for preventive treatment outcomes in this article, however, the American Academy of Neurology may have guidelines for the treatment of chronic tension-type headache, which could include recommendations for preventive treatment 8

Treatment of Tension Headaches

Medication Overuse Warning

• The American Academy of Family Physicians recommends avoiding butalbital-containing compounds due to the high risk of dependence and medication overuse headache, and notes that using acute treatments more than twice weekly increases the risk of progression to chronic daily headache 9

Preventive Treatment

• The American Academy of Family Physicians suggests considering preventive therapy when patients have two or more attacks per month producing disability lasting 3 or more days, or when there is a contraindication to or failure of acute treatments, or when the patient is at risk of medication overuse headache 9

Evidence‑Based Non‑Pharmacological and Procedural Interventions for Tension‑Type Headache

Physical Therapy and Exercise

• Physical therapy is recommended as an adjunctive management option for patients with tension‑type headache, with moderate‑quality evidence supporting its effectiveness in reducing headache frequency and severity【10】.
• Aerobic exercise or progressive strength‑training programs are advised for the prevention of tension‑type headache, showing beneficial effects on headache occurrence in the studied population【10】.

Procedural Intervention

• Greater occipital nerve block may be employed for short‑term relief of tension‑type headache, although the supporting evidence is weak and should be considered only after optimizing pharmacologic and non‑pharmacologic therapies【10】.

Amitriptyline Efficacy in Chronic Tension‑Type Headache

Pharmacologic Prevention

• Amitriptyline is supported by randomized trial evidence as a first‑line preventive medication for chronic tension‑type headache, showing greater efficacy than in migraine prevention and superiority in patients with mixed migraine and tension‑type headache. (Level I evidence – randomized controlled trial) 11