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Background and Aims: Butalbital is an acute headache medication commonly prescribed for tension‐type headache (TTH), although discouraged by guidelines due to a risk of medication overuse headache (MOH). Considering spinal manipulative therapy (SMT) may reduce TTH frequency and intensity, we hypothesized adults with TTH receiving chiropractic SMT would be less likely to receive a butalbital prescription over 2 years versus matched controls not receiving SMT. We secondarily compared likelihood of MOH between cohorts. Methods: We searched a United States medical records database of patients attending academic medical centers for adults with TTH, from 2013 to 2024, excluding those diagnosed with other headaches and seen in inpatient/emergency settings. We divided patients into two cohorts: (1) SMT and (2) non‐SMT, using propensity matching to control for demographics and other variables associated with likelihood of butalbital prescription and MOH. Results: Three thousand one hundred and sixteen patients remained per cohort after matching. The incidence of butalbital prescription was lower in the SMT cohort compared to the non‐SMT cohort (SMT: 1.7%; non‐SMT: 3.8%), yielding an RR (95% CI) of 0.46 (0.33–0.63; p < 0.001). The incidence of MOH was lower in the SMT cohort versus non‐SMT cohort (SMT: 0.5%; non‐SMT: 1.2%), yielding an RR (95% CI) of 0.44 (0.25–0.80; p < 0.001). Conclusion: Adults receiving chiropractic SMT had a significantly lower likelihood of butalbital prescription and, tentatively, MOH compared to matched controls not receiving SMT. These findings support current guideline recommendations favoring SMT in TTH care, though future studies should replicate and compare these findings with other nonpharmacologic clinicians and interventions. [ABSTRACT FROM AUTHOR]