What is the recommended treatment for chronic tension headaches?

Treatment of Chronic Tension Headaches

Amitriptyline is the first-line pharmacological treatment for chronic tension-type headaches, combined with non-pharmacological approaches such as stress management therapy for optimal outcomes.

Pharmacological Treatment

First-Line Treatment

• Amitriptyline is recommended as first-line therapy for chronic tension-type headaches 1, 2
  • Starting dose: Low (10-25mg daily)
  • Gradually titrate to effective dose (typically 25-75mg daily)
  • Take at bedtime to minimize daytime sedation
  • Common side effects: dry mouth, sedation, weight gain, constipation, and potential cardiac dysrhythmias 1

Acute Treatment Options

• Ibuprofen (400mg) or Acetaminophen (1000mg) are recommended for short-term treatment of tension-type headache episodes 1
• Limit acute medication use to no more than twice per week to prevent medication overuse headache 1

Medications to Avoid

• Botulinum toxin injections are not recommended for chronic tension-type headaches (weak against recommendation) 1
• Avoid opioids and barbiturates due to risk of dependency and medication overuse headache 2

Non-Pharmacological Approaches

Stress Management Therapy

• Research shows combined therapy (amitriptyline plus stress management) produces clinically significant (≥50%) reductions in headache index scores in 64% of patients versus 38% with medication alone 3
• Recommended components:
  • Relaxation training
  • Progressive muscle relaxation
  • Cognitive coping strategies
  • Biofeedback

Lifestyle Modifications

• Maintain regular sleep schedule
• Regular meals and adequate hydration
• Moderate exercise program (40 minutes three times weekly) 2
• Identify and avoid personal triggers 2

Treatment Algorithm

1. Initial Approach: Start amitriptyline at low dose (10-25mg at bedtime) AND introduce stress management techniques
2. Acute Episodes: Use ibuprofen 400mg or acetaminophen 1000mg as needed (limit to <2 times/week)
3. Titration: Gradually increase amitriptyline dose over 2-4 weeks to effective level (typically 25-75mg)
4. Assessment: Evaluate effectiveness after 2-3 months of consistent treatment
5. Monitoring: Use headache diary to track:
   • Frequency and severity of headaches
   • Medication use
   • Triggers
   • Response to treatment

Special Considerations

Medication Overuse

• Assess for medication overuse headache in all patients with chronic tension headaches
• If present, withdrawal of overused medication is necessary 1
• Abrupt withdrawal is generally preferred except for opioids 1

Comorbidities

• Depression and anxiety frequently co-occur with chronic tension headaches
• Amitriptyline may provide dual benefit for headaches and mood disorders 1
• Sleep disorders should be addressed as they can exacerbate headaches 2

Common Pitfalls to Avoid

• Inadequate dosing of preventive medications leads to poor outcomes 2
• Premature discontinuation of preventives before reaching full effect (2-3 months) 2
• Not addressing medication overuse perpetuates the headache cycle 2
• Unrealistic expectations for immediate resolution can lead to treatment abandonment 2
• Focusing only on pharmacological treatment without addressing lifestyle factors and stress management 1, 3

Prognosis

• Combined therapy (medication plus stress management) offers the best chance for significant improvement 3
• Patients should be educated that the goal is significant reduction in headache frequency and severity, not complete elimination
• Treatment may need to be continued long-term for sustained benefit