Tension headache medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Hasnain Ali Moryani, MBBS[2] Sabeeh Islam, MBBS[3]

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Tension type headache medical therapy

Medical management of tension-type headache (TTH) consists of acute treatment with simple analgesics, preventive therapy for frequent or disabling headache, evidence-based behavioral interventions, and prevention of medication-overuse headache (MOH). Current evidence supports ibuprofen or acetaminophen as first-line acute therapy and amitriptyline as the best-established pharmacologic preventive option, although the certainty of evidence for many preventive comparisons remains low or very low.

Acute pharmacologic therapy

• Simple analgesics are first-line treatment for episodic TTH.
• The 2023 VA/DoD guideline gives a weak-for recommendation for either:
  • Ibuprofen 400 mg orally as a single acute dose.
  • Acetaminophen 1000 mg orally as a single acute dose.
• A 2023 network meta-analysis found both ibuprofen and acetaminophen superior to placebo for 2-hour pain freedom, without a statistically significant efficacy difference between the two agents.
• Diclofenac potassium, ketoprofen, naproxen sodium, and aspirin have also been studied as acute therapies. In a 2024 Bayesian network meta-analysis, ibuprofen and diclofenac potassium ranked highest for 2-hour pain freedom, ketoprofen had the highest adverse-event rate, and naproxen did not separate significantly from placebo.
• Agent selection should account for comorbidities and medication-specific risks. Acetaminophen may be favored when NSAID-related gastrointestinal or renal risk is a concern; in pregnancy, acetaminophen is the preferred first-line acute agent.
• Analgesic combinations containing caffeine may modestly improve efficacy in patients with an incomplete response to a simple analgesic, but frequent use increases the risk of medication overuse.
• Triptans are not recommended for pure TTH; an apparent triptan response should prompt consideration of coexisting migraine.
• Opioids and butalbital-containing combination products should be avoided for routine TTH treatment because of dependence and medication-overuse risk.

Preventive pharmacologic therapy

Preventive therapy should be considered when TTH is frequent or chronic, causes clinically significant disability, requires acute treatment more than approximately twice weekly, or is inadequately controlled with acute therapy. No validated universal monthly headache-frequency threshold defines when prevention must be initiated; approximately 10 attacks per month is commonly used in clinical practice but is based largely on expert consensus.

Evidence supporting preventive pharmacotherapy is less robust than evidence for acute treatment. A 2026 network meta-analysis found most comparisons to be of low or very-low certainty. Amitriptyline remains the best-established preventive drug, but the dose ranked highest for efficacy in that analysis (100 mg/day) also produced more adverse effects and should not be interpreted as a routine target dose.

Agent	Practical use	Important considerations
Amitriptyline	Best-established first-line preventive medication. A common starting dose is 10–25 mg orally at bedtime. Titrate by approximately 10 mg weekly according to benefit and tolerability to a usual maintenance dose of approximately 30–70 mg at bedtime. If there is no meaningful response after approximately 4 weeks at the maintenance dose, consider an alternative preventive strategy.	Sedation, anticholinergic effects, weight gain, and cardiac/QT effects may limit use. Use particular caution in older adults because of anticholinergic burden, sedation, fall risk, and cardiac conduction/QT concerns.
Mirtazapine	15–30 mg orally at bedtime may be considered when amitriptyline is ineffective or poorly tolerated.	Evidence is less extensive than for amitriptyline.
Venlafaxine and SSRIs/SNRIs	Routine use solely for TTH prevention is not well supported.	A Cochrane review found SSRIs and venlafaxine no more effective than placebo or amitriptyline for headache frequency over short-term follow-up; SSRIs were inferior to tricyclic antidepressants for reducing analgesic intake.

• Preventive benefit develops over several weeks. Approximately 4–8 weeks at an adequate tolerated dose should generally be allowed before treatment is judged ineffective; for amitriptyline, TTH-specific literature supports assessing response after approximately 4 weeks at the achieved maintenance dose.
• In older adults, amitriptyline should generally be started at the lower end of the dose range. Anticholinergic burden, sedation, fall risk, underlying cardiac disease, and QT-prolonging medications should be considered before and during therapy.
• Patients at increased risk for arrhythmia, including those older than 65 years, patients with myocardial hypertrophy or electrolyte disturbances, and those taking other QT-prolonging medications, warrant heightened caution; the VA/DoD guideline advises consideration of cardiology consultation before tricyclic-antidepressant therapy in patients at higher arrhythmia risk.
• OnabotulinumtoxinA is not an established or guideline-endorsed treatment for TTH. Clinical trials have suggested possible benefit, but the evidence is low certainty and it should not be considered standard preventive therapy for TTH.

Non-pharmacologic therapy

• Behavioral interventions may be used alone or with pharmacologic prevention, particularly in chronic or frequent TTH.
• Interventions with the best clinical support include:
  • Cognitive behavioral therapy and structured stress-management therapy.
  • EMG biofeedback.
  • Relaxation training.
• Combining behavioral treatment with pharmacologic prevention may provide greater benefit than either strategy alone in some patients.
• Regular physical activity, consistent sleep, regular meals, and stress-management strategies may be incorporated into treatment plans.
• Acupuncture and physical therapy approaches addressing posture and exercise may provide benefit in selected patients, but evidence is mixed or of lower certainty.
• Spinal manipulation has not demonstrated reliable efficacy for episodic TTH and should not be considered an evidence-based first-line intervention.

Prevention of medication-overuse headache

• Frequent use of acute headache medication can contribute to medication-overuse headache and chronification.
• A practical counseling target is to restrict acute headache medication to no more than 2 days per week whenever feasible.
• Medication-overuse thresholds depend on drug class:
  • Simple analgesics and NSAIDs should be kept below 15 days per month; TTH-specific literature describes regular intake above approximately 14 days per month as medication overuse.
  • Combination analgesics, opioids, and triptans should generally be kept below 10 days per month; TTH-specific literature similarly describes opioid-combination analgesic use above approximately 9 days per month as medication overuse.
  • Opioids and butalbital-containing products may carry clinically important overuse risk at even lower exposure. The VA/DoD guideline cites population-based thresholds of approximately 8 days per month for opioids and 5 days per month for butalbital.
• Butalbital should not be discontinued abruptly in patients with regular or prolonged use because withdrawal can precipitate seizures; withdrawal should be managed with an appropriate supervised taper or withdrawal strategy.
• When medication overuse is present, management includes education, withdrawal or restriction of the overused acute medication, and appropriate preventive treatment.

Special populations

Pregnancy

• Acetaminophen is the recommended first-line acute therapy for TTH during pregnancy; total daily intake should remain at or below the recommended 24-hour maximum of approximately 3.0–4.0 g/day, accounting for acetaminophen contained in combination products.
• NSAIDs should generally be avoided during the first and third trimesters; short-term use may be considered during the second trimester when clinically appropriate.
• Butalbital-containing products and opioids should be avoided because of maternal/fetal safety concerns and medication-overuse risk.
• Relaxation training, cognitive behavioral therapy, and biofeedback are reasonable low-risk adjunctive options during pregnancy.

Older adults

• Amitriptyline should be used cautiously, generally beginning with a low dose, because anticholinergic effects, sedation, fall risk, and cardiac conduction/QT effects may be more clinically important in older adults.
• Review cardiac history, concurrent QT-prolonging medications, electrolyte abnormalities, fall risk, and cumulative anticholinergic burden when selecting and titrating therapy.
• Patients at higher arrhythmia risk, including those older than 65 years, those with myocardial hypertrophy or electrolyte disturbances, and those receiving other QT-prolonging drugs, may warrant cardiology consultation before initiation of a tricyclic antidepressant.

Pediatric patients

• This microchapter addresses adult TTH pharmacotherapy. Adult drug doses should not be extrapolated to children or adolescents; pediatric TTH management should be addressed separately.