Tension-Type Headache and Medication-Overuse Headache

Clinical Snapshot

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]

Recognize the Condition

Primary and secondary headache patterns covered in this chapter

Episodic tension-type headache

Mild to moderate, bilateral, pressing/tightening (non-pulsatile) pain lasting 30 minutes to 7 days. Not aggravated by routine physical activity such as walking or climbing stairs. No more than one of photophobia or phonophobia, and no nausea or vomiting (anorexia may occur). Subclassified as infrequent episodic (fewer than 1 headache day/month on average) or frequent episodic (1-14 headache days/month for at least 3 months).^[3]

Chronic tension-type headache

The same headache character as episodic TTH, but occurring on 15 or more days per month for more than 3 months. Pain often lasts hours or is continuous. No more than one of photophobia, phonophobia, or mild nausea; neither moderate nor severe nausea or vomiting.^[3]

Medication-overuse headache

Headache occurring on 15 or more days per month in a patient with a pre-existing primary headache disorder, developing as a consequence of regular overuse of acute or symptomatic headache medication for more than 3 months, and not better accounted for by another diagnosis. Most patients with MOH have an underlying migraine or tension-type headache; the specific overused medication class determines the MOH subtype (see Assessment & Diagnosis).^[2]

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.

Risk Factors

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]

Red Flags & Refer

Any of the following warrants urgent investigation and/or specialist referral rather than management as tension-type headache or medication-overuse headache:

Sudden, severe "thunderclap" headache reaching maximum intensity within seconds to minutes.
Headache with fever and neck stiffness (meningismus).
New headache after age 50, or a distinct change in pattern from a previously stable, diagnosed headache disorder.
Headache that worsens with straining, coughing, or lying down, or with morning predominance -- suggestive of raised intracranial pressure.
Papilledema on fundoscopic examination.
New focal neurologic deficit, seizure, or altered level of consciousness.
The first or worst headache of the patient's life.
Headache triggered by unusual precipitants -- cough, exertion, or sexual activity.
Recent significant head trauma, or a history of malignancy, immunocompromise, or anticoagulant use.
New headache in pregnancy or the postpartum period.

Assessment & Diagnosis

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

Subtype	Frequency	Duration	Required features
Infrequent episodic TTH	Under 1 day/month on average (under 12 days/year)	30 minutes to 7 days	At least 2 of: bilateral location, pressing/tightening (non-pulsatile) quality, mild-to-moderate intensity, not aggravated by routine activity. Plus: no nausea/vomiting and no more than one of photophobia/phonophobia.
Frequent episodic TTH	1-14 days/month for at least 3 months (12-179 days/year)	30 minutes to 7 days	Same as infrequent episodic TTH.
Chronic TTH	15 or more days/month for more than 3 months (180 or more days/year)	Hours to continuous	Same bilateral/pressing/not-aggravated features; no more than one of photophobia, phonophobia, or mild nausea, and neither moderate nor severe nausea/vomiting.

^[3]

Tension-type headache vs. migraine

Parameter	Tension-type headache	Migraine
Laterality	Bilateral	Typically unilateral
Character	Pressing/tightening, non-pulsatile	Pulsating/throbbing
Severity	Mild to moderate	Moderate to severe
Effect of routine activity	Not aggravated	Aggravated -- patient avoids or stops activity
Associated symptoms	None, or at most one of photophobia/phonophobia	Nausea and/or vomiting common; photophobia and phonophobia (both) common
Aura	Absent	Present in a minority

^[1]

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

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

Headache occurring on 15 or more days per month in a patient with a pre-existing primary headache disorder.
Regular overuse for more than 3 months of one or more acute/symptomatic headache medications.
Not better accounted for by another ICHD-3 diagnosis.

^[2]

Overuse thresholds by drug class

Drug class	Overuse threshold
Simple analgesics -- acetaminophen, ASA, or an NSAID used alone	15 or more days/month
Triptans	10 or more days/month
Opioids	10 or more days/month
Ergotamine	10 or more days/month
Combination analgesics (e.g., containing caffeine, codeine, or butalbital)	10 or more days/month

Thresholds apply once the pattern has persisted for more than 3 months. A patient combining different acute medications on different days should keep their total combined days of acute-medication use under 10 days/month if any single component is a triptan, ergotamine, opioid, or combination analgesic.^[5]^[2]

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

When neuroimaging is not indicatedRoutine neuroimaging is not indicated in a patient with a normal neurologic examination who meets diagnostic criteria for tension-type headache or migraine and has no red flags -- this applies even when the headache is frequent, longstanding, or the patient specifically requests it. Careful explanation of the diagnosis is generally more appropriate than imaging for reassurance.^[5]

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

Treatment Targets

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.

Choose Initial Treatment

Direct treatment rule

Acute treatment of episodic tension-type headache

1st line acetaminophen 1000 mg PO, or an NSAID -- ibuprofen 200-400 mg, naproxen 375-550 mg, or ASA 500-1000 mg PO. All are level A evidence for episodic TTH; ibuprofen has the most favourable gastrointestinal side-effect profile among the NSAIDs.^[3]

2nd choice a simple analgesic or NSAID combined with caffeine 65-200 mg. Effective, but more likely than a simple analgesic or NSAID alone to drive medication-overuse headache with frequent use -- reserve for patients not adequately relieved by first-line therapy.^[3]

Avoid triptans Triptans are highly effective for migraine but most likely have no clinically relevant effect in tension-type headache and cannot be recommended -- prescribing or recommending one for TTH is a genuine, avoidable error, not merely a missed opportunity.^[3]

Avoid opioids and butalbital/codeine combinations Neither has a role in first-line TTH therapy; both carry a materially higher risk of driving medication-overuse headache and dependence than a simple analgesic or NSAID.^[5]^[3]

Avoid muscle relaxants Not demonstrated effective in episodic tension-type headache.^[3]

Frequent episodic or chronic tension-type headache

1st line -- genuinely first-line, not an adjunct non-pharmacologic therapy: cognitive-behavioural therapy, relaxation training, EMG biofeedback, and/or physical therapy. Consider before or alongside preventive pharmacotherapy, since analgesics are often ineffective and carry medication-overuse risk in this population.^[3]

1st line preventive drug amitriptyline, started at low dose and titrated upward (see Drug Tables). The only agent with a clinically relevant, consistently demonstrated prophylactic effect in chronic tension-type headache.^[3]

2nd choice preventive mirtazapine or venlafaxine, when amitriptyline is not effective or not tolerated.^[3]

Medication-overuse headache

Educate first Every patient meeting overuse criteria should be educated on the diagnosis and the causal role of the overused medication -- education and counselling alone are an effective initial strategy in patients overusing simple analgesics or triptans without major psychiatric comorbidity.^[2]

Withdraw the overused medication when education alone is insufficient, or from the outset in more complex overuse. Simple analgesics, triptans, and ergotamine can be stopped abruptly on an outpatient basis. Opioids, barbiturates, and benzodiazepines require slow, tapered withdrawal -- refer for specialist-directed tapered withdrawal (inpatient or daycare setting) in these cases, and in patients with significant psychiatric comorbidity or a previous failed withdrawal attempt.^[2]

Consider starting preventive therapy concurrently with withdrawal rather than waiting -- some evidence supports parallel initiation, though the optimal timing (early vs. after withdrawal is complete) remains unresolved.^[2]

Non-Pharmacologic Treatment

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]

Pharmacologic Treatment Options

Drug / intervention	Role	Dose / use	Important adverse effects	Teaching points
Acetaminophen Preferred	Acute episodic tension-type headache	1000 mg PO Q4-6H PRN; maximum 4000 mg/day	Hepatotoxicity in overdose or with chronic high-dose use	Preferred first-line acute option; less GI risk than NSAIDs. Limit to under 15 days/month to avoid medication-overuse headache.
Ibuprofen Preferred	Acute episodic tension-type headache	200-400 mg PO Q4-6H PRN (up to 800 mg/dose); maximum 1200 mg/day self-care, higher under medical supervision	GI upset, bleeding risk	Most favourable GI side-effect profile among the NSAIDs studied in TTH. Limit to under 15 days/month.
Naproxen Preferred	Acute episodic tension-type headache; also used as bridge therapy during medication-overuse withdrawal	375-550 mg PO, may repeat once after 8-12H. Withdrawal bridge: 500 mg PO BID, maximum 3 days within the first week	GI upset, bleeding risk	Longer-acting than ibuprofen. Limit to under 15 days/month outside a supervised withdrawal bridge.
Acetylsalicylic acid (ASA) Preferred	Acute episodic tension-type headache	500-1000 mg PO Q4-6H PRN; maximum 4000 mg/day	GI upset, bleeding risk	Limit to under 15 days/month.
Simple analgesic/NSAID + caffeine combination Alternative	Acute tension-type headache when a simple analgesic or NSAID alone is insufficient	Caffeine 65-200 mg added to acetaminophen, ASA, or an NSAID per product	As for the base analgesic, plus caffeine-related insomnia/jitteriness; caffeine withdrawal can itself provoke headache	2nd choice given a materially higher risk of driving medication-overuse headache than a simple analgesic alone. Limit to under 10 days/month.
Any triptan Avoid	Not indicated for tension-type headache	Not applicable	Not applicable	No clinically relevant effect in TTH -- do not prescribe or recommend for this diagnosis. See the Migraine chapter for correct triptan selection and dosing.
Opioids and butalbital/codeine-containing combinations Avoid	Not indicated for tension-type or medication-overuse headache	Not applicable	Sedation, dependence, worsens headache trajectory	Materially increases the risk of medication-overuse headache and dependence; avoid as first-line or routine therapy.
Amitriptyline Preferred	Preventive therapy, chronic tension-type headache	Start 10-25 mg PO HS; titrate by 10-25 mg weekly to a maintenance dose of 30-75 mg/day, given 1-2 hours before bedtime	Dry mouth, drowsiness, dizziness, constipation, weight gain; QTc prolongation risk	Only agent with a clinically relevant, consistently demonstrated preventive effect in chronic TTH. Allow a full 4-week trial at maintenance dose before judging response.
Mirtazapine Alternative	Preventive therapy, chronic TTH -- 2nd choice	30 mg PO once daily	Drowsiness, weight gain	Use when amitriptyline is not effective or not tolerated.
Venlafaxine Alternative	Preventive therapy, chronic TTH -- 2nd choice	150 mg PO once daily (extended-release)	Nausea, dizziness, dose-related hypertension	Use when amitriptyline is not effective or not tolerated.

Special Populations

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.

Monitoring & Follow-Up

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.

Treatment Failure / Next Step

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).
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]
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.
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]
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]
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]
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]
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]

Common Errors to Avoid

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.

Clinical Decision Algorithm

Initial evaluation and classification

Adult presents with headache

Screen for red flags on history and examination (see Red Flags & Refer)

Red flag present, or abnormal neurologic examination

Urgent investigation and/or specialist referral -- do not manage as a primary headache disorder

No red flags, normal examination

Take a full history including headache pattern, associated symptoms, and acute-medication use in days/month; apply ICHD-3 criteria^[1]

Bilateral, pressing, not aggravated by activity, no/minimal associated symptoms

Manage as tension-type headache -- proceed to the acute treatment algorithm

Unilateral, pulsating, aggravated by activity, associated nausea/photophobia/phonophobia

Manage as migraine -- see the separate Migraine chapter

Headache 15+ days/month with a qualifying acute-medication overuse pattern for over 3 months

Evaluate for medication-overuse headache -- proceed to the detection & withdrawal algorithm

Acute treatment of episodic tension-type headache

Confirmed episodic tension-type headache, acute attack

Acetaminophen 1000 mg, or an NSAID (ibuprofen, naproxen, or ASA) at first-line dose

Insufficient relief

Try a different first-line agent

Switch among acetaminophen/ibuprofen/naproxen/ASA before escalating

Still insufficient after an adequate trial

Consider a combination analgesic with caffeine (2nd choice) -- monitor frequency closely

Do not add a triptan, opioid, or barbiturate-containing combination -- none are appropriate for tension-type headache^[3]

Attacks are frequent (1 or more days/week) or evolving toward chronic tension-type headache

Reassess for preventive-therapy candidacy -- proceed to the chronic TTH / prevention algorithm

Frequent episodic or chronic tension-type headache: prevention

Tension-type headache 1+ days/week, or chronic (15+ days/month, over 3 months)

Start non-pharmacologic therapy: cognitive-behavioural therapy, relaxation training, and/or EMG biofeedback -- genuinely first-line, not just an adjunct^[3]

Start amitriptyline 10-25 mg PO HS; titrate by 10-25 mg weekly toward 30-75 mg/day

Reassess after a full 4-week trial at maintenance dose

Meaningful improvement

Continue; reattempt discontinuation in 6-12 months

Not effective or not tolerated

Switch to mirtazapine 30 mg/day or venlafaxine 150 mg/day

Medication-overuse headache: detection and withdrawal

Ask every patient, at every visit, how many days per month they use any acute headache medication^[5]

Meets overuse threshold: simple analgesics 15+ days/month, or triptans/opioids/ergotamine/combination analgesics 10+ days/month, for over 3 months^[2]

Educate the patient on the diagnosis and the causal role of the overused medication -- effective alone in many patients without major psychiatric comorbidity

Overusing simple analgesics, triptans, or ergotamine, with no major psychiatric comorbidity

Abrupt outpatient withdrawal; bridge with naproxen 500 mg PO BID (maximum 3 days in week 1) or acetaminophen 1000 mg PO on demand if needed

Overusing opioids, barbiturates, or benzodiazepines; major psychiatric comorbidity; or a previous failed withdrawal

Refer for specialist-directed tapered withdrawal -- inpatient or daycare setting

Start or continue preventive therapy for the underlying primary headache disorder, in parallel with or shortly after withdrawal

Close follow-up every 3-6 months -- most relapses into overuse occur within the first year

Drug Tables

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.

Drug	Dosage	Adverse effects	Drug interactions	Comments
Acetaminophen	1000 mg PO Q4-6H PRN; maximum 4000 mg/day (reduce in significant hepatic impairment or heavy alcohol use)	Hepatotoxicity in overdose or chronic high-dose use	Can increase INR in patients on warfarin -- check INR if used at 2 g/day or more for 3 or more consecutive days	Preferred where GI or renal risk is a concern.
Ibuprofen	200-400 mg PO Q4-6H PRN (up to 800 mg/dose); maximum 1200 mg/day self-care, higher under medical supervision	GI upset, bleeding risk; renal impairment with dehydration	Increased anticoagulant effect and bleeding risk with warfarin, SSRIs, or corticosteroids	Most favourable GI side-effect profile among the NSAIDs studied in TTH.
Naproxen	375-550 mg PO, may repeat once after 8-12H	GI upset, bleeding risk	Increased anticoagulant effect and bleeding risk with warfarin, SSRIs, or corticosteroids	Longer-acting than ibuprofen. Also used as a bridge during medication-overuse withdrawal -- see below.
Acetylsalicylic acid (ASA)	500-1000 mg PO Q4-6H PRN; maximum 4000 mg/day	GI upset, bleeding risk	Increased bleeding risk with anticoagulants and other NSAIDs	Avoid in patients under 18 years given Reye syndrome risk -- see the Headache in Children chapter for pediatric dosing.
Diclofenac potassium	12.5-25 mg PO per dose	GI upset, bleeding risk	Increased anticoagulant effect and bleeding risk with warfarin, SSRIs, or corticosteroids	Only doses of 12.5-25 mg have actually been tested in TTH trials; higher doses used in migraine are not established for TTH.

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.

Drug	Dosage	Adverse effects	Drug interactions	Comments
Acetaminophen / codeine	Per product; use only when specifically indicated, not as routine TTH therapy	Sedation, constipation, dependence with regular use	Additive CNS depression with alcohol, benzodiazepines, or other opioids	Codeine-containing combinations meaningfully raise medication-overuse and dependence risk -- avoid as first- or second-line TTH therapy.

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.

Drug	Dosage	Adverse effects	Drug interactions	Comments
Triptans (any agent)	Not applicable -- not indicated for TTH	Not applicable	Not applicable	Most likely have no clinically relevant effect in tension-type headache; see the Migraine chapter for correct use.
Opioids	Not applicable -- not indicated for TTH	Sedation, dependence	Additive CNS depression with other sedating drugs	Materially increases medication-overuse and dependence risk without added efficacy over a simple analgesic or NSAID.
Muscle relaxants	Not applicable -- not indicated for TTH	Sedation	Additive CNS depression with other sedating drugs	Not demonstrated effective in episodic tension-type headache.

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.

Drug	Dosage	Adverse effects	Drug interactions	Comments
Amitriptyline	Start 10-25 mg PO HS; titrate by 10-25 mg weekly to a maintenance dose of 30-75 mg/day, given 1-2 hours before bedtime	Dry mouth, drowsiness, dizziness, constipation, weight gain; QTc prolongation risk	Metabolized by cytochrome P450 -- clearance affected by inhibitors (e.g., fluoxetine, erythromycin) and inducers (e.g., carbamazepine, phenytoin); avoid with an MAOI	Drug of first choice -- the only agent with a clinically relevant, consistently demonstrated preventive effect in chronic TTH.
Mirtazapine	30 mg PO once daily	Drowsiness, weight gain	Additive CNS depression with alcohol or other sedating drugs; avoid with an MAOI	Drug of second choice -- use when amitriptyline is not effective or not tolerated.
Venlafaxine	150 mg PO once daily (extended-release)	Nausea, dizziness, dose-related hypertension, particularly at higher doses	Potentially fatal reaction with an MAOI; CYP2D6/CYP3A4 inhibitors may increase venlafaxine levels	Drug of second choice -- use when amitriptyline is not effective or not tolerated. Taper to discontinue rather than stopping abruptly.

Medication-overuse withdrawal -- bridge and rescue therapy

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

Drug	Dosage	Adverse effects	Drug interactions	Comments
Naproxen (withdrawal bridge)	500 mg PO BID, maximum 3 days within the first week of withdrawal	GI upset, bleeding risk	Increased anticoagulant effect and bleeding risk with warfarin, SSRIs, or corticosteroids	A long-acting NSAID used specifically as bridge therapy during MOH withdrawal, not as routine acute TTH therapy.
Metoclopramide	10 mg PO/IM, up to 3 times daily as needed for withdrawal-associated nausea	Extrapyramidal symptoms, akathisia, sedation	Additive sedation with other CNS depressants	Antidopaminergic bridge option for nausea during withdrawal; often combined with diphenhydramine to reduce extrapyramidal risk.
Diphenhydramine	25-50 mg PO/IM as needed	Sedation, dry mouth, anticholinergic effects	Additive sedation with alcohol or other CNS depressants	Given alongside a dopamine-antagonist antiemetic to reduce extrapyramidal risk, not as a primary bridge agent.

References

The International Classification of Headache Disorders, 3rd edition — Cephalalgia, Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018;38(1):1-211
European Academy of Neurology guideline on the management of medication-overuse headache — European Journal of Neurology, European Academy of Neurology (Diener HC, Antonaci F, Braschinsky M, et al.). Eur J Neurol 2020;27(7):1102-1116
EFNS guideline on the treatment of tension-type headache -- Report of an EFNS task force — European Journal of Neurology, EFNS Task Force (Bendtsen L, Evers S, Linde M, Mitsikostas DD, Sandrini G, Schoenen J). Eur J Neurol 2010;17(11):1318-1325
The role of community pharmacists in managing common headache disorders, and their integration within structured headache services — Journal of Headache and Pain, European Headache Federation and Lifting The Burden, endorsed by the International Pharmaceutical Federation (BaniHani H, Lampl C, MaassenVanDenBrink A, et al.). J Headache Pain 2025;26:100
Headache: Four Things Physicians and Patients Should Question — Choosing Wisely Canada, Canadian Headache Society. Choosing Wisely Canada, last updated June 2017

Professional reference only. Apply clinical judgment and verify patient-specific decisions against current authoritative guidance and product information.