Tension Headache Management

First-Line Treatment Options

The VA/DoD Clinical Practice Guideline recommends ibuprofen 400 mg or acetaminophen 1000 mg as first-line treatments for tension-type headache with a "weak for" recommendation, indicating positive but moderate strength of evidence 2

For patients with significant nausea accompanying their tension headache, adding an antiemetic may be beneficial 3
Limit acute therapy to no more than twice weekly to prevent medication-overuse headache 3
For patients with chronic tension-type headache (≥15 headache days per month), preventive treatment with amitriptyline should be considered rather than relying solely on abortive medications 2, 4

Start with either ibuprofen 400 mg or acetaminophen 1000 mg at the onset of tension headache, as recommended by the American College of Physicians 2
For patients experiencing frequent tension headaches (>2 per week), consider preventive therapy with amitriptyline rather than increasing acute medication use, as suggested by the American College of Physicians 2, 4

Overuse of acute medications (>10-15 days per month) can lead to medication-overuse headache, which is difficult to treat, according to Praxis Medical Insights 3
Tension-type headache can sometimes be difficult to distinguish from migraine; if standard tension headache treatments fail, reassessment of diagnosis may be warranted, as noted in Nature Reviews Neurology 5
Botulinum toxin injections are not recommended for tension-type headache and should be avoided, as stated by the American College of Physicians 2, 4