Tension-Type Headache and Medication-Overuse Headache

Tension-type headache (TTH) is the most common primary headache disorder encountered in practice. It produces a dull, bilateral, pressing or tightening pain that -- unlike migraine -- is not aggravated by routine physical activity and is not accompanied by significant nausea, vomiting, or more than one of photophobia/phonophobia.^[1]

This chapter also covers medication-overuse headache (MOH), a secondary headache disorder that develops directly out of how TTH and other chronic headache is managed: the same acute analgesics used to relieve headache, taken too often, drive the underlying headache pattern into a more frequent and harder-to-treat state. MOH is not a separate problem layered on top of TTH -- it is frequently a direct consequence of treating it, which is why both are covered together here.^[2]

Migraine is a genuinely distinct primary headache disorder -- unilateral, pulsating, aggravated by routine activity, and typically accompanied by nausea and/or photophobia and phonophobia -- and has its own dedicated chapter. The differential matters clinically because it changes acute drug selection: a triptan appropriate for migraine has no meaningful role in TTH (see Choose Initial Treatment).^[3]

Community pharmacists are frequently the first point of contact for a person managing headache with over-the-counter therapy, and are well placed to identify emerging overuse at the point of OTC sale and deliver the education that prevents MOH from developing in the first place.^[4]

Migraine remains the key differential -- unilateral, pulsating, moderate-to-severe, aggravated by routine activity, and associated with nausea and/or photophobia/phonophobia. See the comparison table in Assessment & Diagnosis, and the separate Migraine chapter for migraine's full diagnostic and treatment detail.

• Stress -- mental or physical -- is the most frequently reported trigger for tension-type headache.
• Irregular or inadequate meals; dehydration.
• Sleep disturbance -- insufficient sleep, poor sleep quality, or an irregular sleep-wake schedule.
• Poor posture and musculoskeletal tension, particularly of the pericranial and cervical muscles.
• High intake or withdrawal of caffeine.
• Psychiatric comorbidity -- anxiety and depression are common in chronic tension-type headache and should be actively screened for, not just assumed.^[3]
• Female sex -- TTH affects women only slightly more often than men, a much smaller gender skew than migraine.^[3]
• Frequent use of acute headache medication -- the single most important modifiable risk factor for developing medication-overuse headache, regardless of the underlying primary headache disorder.^[2]
• Other chronic pain conditions, tranquilizer use, and psychiatric comorbidity are specifically associated with medication-overuse headache.^[2]

Diagnostic criteria for tension-type headache (ICHD-3)

Tension-type headache vs. migraine

See the Migraine chapter for complete migraine diagnostic and treatment detail.

Diagnostic criteria for medication-overuse headache (ICHD-3)

Overuse thresholds by drug class

History

• Headache pattern: location, quality, duration, frequency, and effect of routine physical activity -- key to distinguishing tension-type headache from migraine.
• Acute-medication use in days per month -- ask directly and specifically at every assessment. This single question is the most effective way to detect medication-overuse headache; patients rarely volunteer it unprompted, and both prescription and nonprescription/over-the-counter use must be counted.^[5]
• A headache diary completed over at least 4 weeks helps establish the diagnosis, identify triggers, and quantify acute-medication use.^[3]
• Associated symptoms: nausea, vomiting, photophobia, phonophobia -- their presence and degree helps separate TTH from migraine.
• Psychiatric screen: anxiety and depression, common in both chronic TTH and MOH.
• Triggers: stress, sleep, meals/hydration, caffeine, posture, menstrual cycle.
• Full medication history, including nonprescription analgesics, combination products, and any recent change to an existing preventive medication.

Physical examination

• Vital signs and a general examination, including palpation of the pericranial and cervical musculature for tenderness.
• A full neurologic examination, including fundoscopy for papilledema.
• Palpation of the temporal arteries and assessment for temporomandibular joint dysfunction where relevant.

Investigations

Reserve neuroimaging and further investigation for patients with a red flag (see Red Flags & Refer).

• Relieve acute tension-type headache pain effectively with each attack.
• Prevent progression from episodic to chronic tension-type headache.
• Prevent medication-overuse headache by keeping acute-medication use under the frequency thresholds that define overuse.
• Detect medication-overuse headache early by asking about acute-medication frequency at every visit.
• For confirmed medication-overuse headache: successfully withdraw the overused medication and re-establish an episodic headache pattern.
• For chronic tension-type headache: achieve a clinically meaningful reduction in headache days and disability with preventive therapy, while being honest that efficacy is often modest and full resolution is uncommon.^[3]
• Reduce headache-related disability and missed work/school, and improve quality of life.

• Cognitive-behavioural therapy -- helps the patient identify and challenge the thoughts and stress responses that generate and aggravate tension-type headache; genuinely first-line for frequent episodic and chronic TTH, not merely an adjunct to drug therapy.^[3]
• Relaxation training -- breathing exercises, progressive muscle relaxation, and meditation-based techniques to recognize and control tension as it arises.
• EMG (electromyographic) biofeedback -- trains the patient to recognize and control pericranial muscle tension using real-time feedback; the psycho-behavioural treatment with the most consistent supporting evidence in TTH.^[3]
• Physical therapy and posture correction -- may help patients with frequent tension-type headache, particularly where cervical or pericranial muscle tenderness is prominent.
• Identify and address specific triggers: stress, irregular or skipped meals, dehydration, poor sleep, and high caffeine intake or caffeine withdrawal.
• Maintain a regular sleep-wake schedule and adequate hydration.
• Regular physical exercise.
• Reassurance and education about the benign nature of the diagnosis -- explaining that muscle tension and central pain-processing changes underlie the headache, not a structural or dangerous cause, has a genuine therapeutic effect in its own right.^[3]
• For medication-overuse headache specifically: patient education about the causal role of the overused medication is itself an effective first-line intervention. Increased awareness among the public and among pharmacy staff of the relationship between frequent acute-medication use and headache chronification helps prevent MOH from developing in the first place -- this is the single most valuable pharmacist contribution to headache care.^[2][4]

Pregnancy

Acetaminophen is the preferred acute analgesic for tension-type headache in pregnancy. NSAIDs should be avoided in the third trimester and used only intermittently, with caution, earlier in pregnancy. Amitriptyline has been used in pregnancy when a preventive agent is genuinely needed, but data are limited -- involve the prescriber and exhaust non-pharmacologic options first. New headache in pregnancy or the postpartum period is a red flag requiring assessment (see Red Flags & Refer), not an assumption of tension-type headache.

Breastfeeding

Acetaminophen, ibuprofen, and naproxen are compatible with breastfeeding at standard doses. Amitriptyline is generally considered compatible; involve the prescriber before starting or continuing it through breastfeeding.

Older adults

Start amitriptyline at the lowest dose and titrate more slowly, given greater sensitivity to anticholinergic and sedative effects and a higher fall risk. Consider a baseline ECG before starting a tricyclic antidepressant in a patient with cardiac risk factors, given QTc-prolongation risk. NSAIDs carry a higher GI-bleeding and renal risk in this population -- prefer acetaminophen where appropriate and limit NSAID dose and duration.

Hepatic impairment

Reduce the maximum daily acetaminophen dose in significant hepatic impairment or heavy alcohol use, and avoid regular high-dose use.

Renal impairment

Avoid NSAIDs, or use with caution and adequate hydration; prefer acetaminophen as the first-line acute option.

Psychiatric comorbidity

Anxiety and depression are common in both chronic tension-type headache and medication-overuse headache -- screen for both at diagnosis and at follow-up, since untreated psychiatric comorbidity is a barrier to successful withdrawal and a risk factor for relapse after detoxification.^[2]

Complex or high-risk medication overuse

Opioid, barbiturate, or benzodiazepine overuse; significant psychiatric comorbidity; or a previous failed withdrawal attempt all warrant referral to a headache specialist or a multidisciplinary program rather than an unsupported outpatient withdrawal attempt in primary care or community pharmacy.^[2]

Children and adolescents

Pediatric tension-type headache, migraine, and medication-overuse headache -- including weight-based dosing -- are covered in the Headache in Children chapter; the adult dosing and drug choices in this chapter do not apply to pediatric patients.

Maintain a headache diary throughout assessment and treatment -- it is the most useful tool for confirming the diagnosis, judging whether an acute or preventive strategy is actually working, and catching an emerging medication-overuse pattern before it becomes established.^[3]

At every follow-up visit, ask specifically about the number of days per month the patient has used any acute headache medication -- prescription and nonprescription/over-the-counter alike. Asked routinely, rather than only when overuse is already suspected, this single question is the most effective way to detect medication-overuse headache early -- and it is a question every pharmacist is well positioned to ask at the point of OTC analgesic sale.^[5][2][4]

For amitriptyline and other preventive therapy: titrate slowly and allow a full 4-week trial at the maintenance dose before concluding a lack of response; switch to a second-choice agent (mirtazapine or venlafaxine) if there is no meaningful benefit by then. Attempt discontinuation of a successful preventive agent every 6-12 months to reassess ongoing need.^[3]

After successful withdrawal from an overused medication, arrange closer follow-up -- every 3-6 months is reasonable in a patient who required withdrawal -- since relapse back into overuse is common and most relapses occur within the first year.^[2]

Monitor amitriptyline for anticholinergic effects, sedation, weight gain, and QTc-prolongation risk, particularly when combined with other QTc-prolonging drugs. Monitor NSAID use for GI and renal tolerance with frequent or prolonged use.

1. Reconfirm the diagnosis -- recheck for red flags, re-examine, and reconsider whether the pattern still genuinely meets tension-type headache criteria or has evolved (for example, toward migraine or a secondary cause).
2. Explicitly screen for medication-overuse headache before concluding that an acute or preventive therapy has simply stopped working -- ask about days-per-month of every acute medication, prescription and nonprescription.^[5]
3. For acute treatment failure: confirm an adequate dose was used early in the attack; consider switching among first-line agents (acetaminophen, ibuprofen, naproxen, ASA) before escalating to a combination-caffeine product.
4. Do not add a triptan for tension-type headache regardless of how refractory the acute attacks seem -- it is not effective for this diagnosis and does not represent a legitimate next step.^[3]
5. For preventive treatment failure: confirm a genuine 4-week trial at an adequate maintenance dose (30-75 mg/day amitriptyline) before concluding failure -- many perceived failures are actually inadequate trials.^[3]
6. If amitriptyline genuinely fails an adequate trial or is not tolerated, switch to mirtazapine or venlafaxine rather than simply increasing the amitriptyline dose further.^[3]
7. For confirmed medication-overuse headache: educate the patient, withdraw the overused medication (abruptly for simple analgesics/triptans/ergotamine; tapered for opioids/barbiturates/benzodiazepines), and start or continue a preventive agent.^[2]
8. If withdrawal fails, relapses, or involves opioid/barbiturate/benzodiazepine overuse, significant psychiatric comorbidity, or a prior failed attempt: refer to a headache specialist or multidisciplinary program for a structured detoxification protocol, which may include inpatient or daycare withdrawal.^[2]

• Prescribing or recommending a triptan for tension-type headache -- it has no meaningful effect in this diagnosis and is a genuine, avoidable prescribing error, not just a low-value choice.^[3]
• Not asking about days-per-month of acute-medication use at follow-up -- the single most common way an emerging medication-overuse headache pattern is missed.^[5]
• Recommending or continuing an opioid, or a combination product containing codeine, caffeine, or butalbital, as routine therapy for tension-type headache.
• Treating chronic tension-type headache with analgesics alone, without offering non-pharmacologic therapy or considering preventive pharmacotherapy -- analgesics are often ineffective in chronic TTH, and their frequent use itself risks medication-overuse headache.^[3]
• Concluding amitriptyline has failed before a genuine 4-week trial at maintenance dose.
• Attempting abrupt withdrawal in a patient overusing opioids, barbiturates, or benzodiazepines -- this group needs a tapered, often specialist-directed withdrawal.^[2]
• Ordering routine neuroimaging in a patient with a normal examination and no red flags -- this does not improve outcomes and delays appropriate management.^[5]
• Missing a secondary cause by assuming every bilateral headache is tension-type without a red-flag screen.
• Confusing tension-type headache with migraine (or vice versa) and selecting the wrong acute drug class as a result -- see the Migraine chapter for the migraine-specific approach.

How to use this table: Doses are adult doses and require patient-specific confirmation, including hepatic/renal adjustment where relevant. Select any drug name to open its complete Pharmasist Drug Database page.

Simple analgesics and NSAIDs -- acute tension-type headache

First-line acute therapy. Limit any of these, used alone, to under 15 days per month to avoid medication-overuse headache.

Combination analgesics

Combinations of a simple analgesic or NSAID with caffeine are more effective than either drug alone, but are regarded as a 2nd choice given a materially higher risk of driving medication-overuse headache with frequent use. Combinations containing codeine or butalbital should not be used routinely for tension-type headache.

Not recommended for tension-type headache

Effective for migraine, but without a meaningful role in TTH -- avoid prescribing or recommending any of the following for this diagnosis.

Preventive pharmacotherapy -- chronic tension-type headache

Preventive therapy should be considered in chronic TTH and in very frequent episodic TTH. Allow a full 4-week trial at maintenance dose before judging a lack of response, and reattempt discontinuation of a successful agent every 6-12 months.

Medication-overuse withdrawal -- bridge and rescue therapy

Used during withdrawal from an overused acute medication to control breakthrough headache without perpetuating the overuse pattern.