What is the recommended first-line approach for tension headache prophylaxis?

From the Guidelines

The recommended first-line approach for tension headache prophylaxis is amitriptyline, typically started at a low dose of 50 mg and gradually increased as needed. This recommendation is based on the most recent and highest quality study available, which suggests that amitriptyline is effective in reducing the frequency and severity of tension headaches 1.

Key Points to Consider:

• Amitriptyline should be started at a low dose and gradually increased as needed and tolerated, up to a maximum dose of 100 mg daily.
• Treatment should continue for at least 3-6 months before attempting to taper if headaches are well-controlled.
• Other tricyclic antidepressants like nortriptyline may be substituted if amitriptyline causes excessive side effects.
• Non-pharmacological approaches, including stress management, regular exercise, adequate sleep, and trigger avoidance, should be used concurrently.
• For patients who cannot tolerate tricyclic antidepressants, alternative options include venlafaxine or topiramate.

Rationale:

The study published in 2023 1 provides the most recent and comprehensive guidance on the management of headache disorders, including tension headaches. The recommendation for amitriptyline as a first-line treatment for tension headache prophylaxis is based on the available evidence, which suggests that it is effective in reducing the frequency and severity of headaches.

Important Considerations:

• Prophylactic treatment is typically considered when tension headaches occur more than 2-3 times per week or significantly impact daily functioning.
• The use of amitriptyline and other tricyclic antidepressants may be associated with side effects, such as drowsiness, dry mouth, constipation, and weight gain.
• Patients should be closely monitored and the treatment plan adjusted as needed to minimize side effects and optimize efficacy.

From the FDA Drug Label

For outpatients, 75 mg of amitriptyline HCl a day in divided doses is usually satisfactory. If necessary, this may be increased to a total of 150 mg per day The usual maintenance dosage of amitriptyline HCl is 50 to 100 mg per day. In some patients, 40 mg per day is sufficient.

The recommended first-line approach for tension headache prophylaxis using amitriptyline is to initiate therapy at a low dose, typically 75 mg per day in divided doses, with the option to increase to 150 mg per day if necessary. The maintenance dosage is usually between 50 to 100 mg per day, with some patients requiring as little as 40 mg per day 2.

From the Research

Tension Headache Prophylaxis

• The recommended first-line approach for tension headache prophylaxis involves the use of tricyclic antidepressants, such as amitriptyline, due to their efficacy in reducing headache frequency and intensity 3, 4, 5.
• Amitriptyline has been shown to be moderately effective in chronic tension-type headache, with studies indicating a significant reduction in headache activity, analgesic medication use, and headache-related disability 3, 4, 5.
• The use of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for tension-type headache prophylaxis is not supported by strong evidence, with studies suggesting they are no more effective than placebo or amitriptyline in reducing headache frequency 6.
• Behavioral therapies, such as stress management and relaxation exercises, may also be beneficial in reducing headache frequency and intensity, and can be used in combination with pharmacological treatments 3, 7.
• The choice of prophylactic treatment should be individualized, taking into account the frequency, duration, and intensity of headaches, as well as the presence of any underlying trigger factors 7.

Key Findings

• Amitriptyline reduces headache frequency, duration, and intensity, and is effective in the prophylactic treatment of chronic tension-type headache 3, 4, 5.
• SSRIs and SNRIs are not recommended as first-line treatments for tension-type headache prophylaxis due to lack of evidence supporting their efficacy 6.
• Behavioral therapies, such as stress management and relaxation exercises, may be beneficial in reducing headache frequency and intensity 3, 7.

Treatment Considerations

• Tricyclic antidepressants, such as amitriptyline, are the initial drug of choice for tension-type headache prophylaxis 4, 5, 7.
• Prophylactic treatment should be individualized, taking into account the frequency, duration, and intensity of headaches, as well as the presence of any underlying trigger factors 7.
• The use of prophylactic treatment should be considered when headaches are frequent, severe, or disabling, and when acute treatment is inadequate 4, 7.