What are the next steps for a patient with daily tension-type headaches not improved with triptans, propranolol (propranolol hydrochloride) daily, and daily magnesium (magnesium oxide), with normal laboratory results and blood pressure?

Management of Daily Tension-Type Headaches Refractory to Current Treatment

For patients with daily tension-type headaches not responding to triptans, propranolol, and magnesium, amitriptyline should be initiated as the next therapeutic option. 1, 2

Assessment of Current Treatment Failure

Before adding new treatments, evaluate:

• Medication overuse: Frequent use of triptans (which are ineffective for tension-type headaches) may lead to medication overuse headache
• Propranolol dosing: Ensure adequate dosing (80-240 mg/day) 2, 3
• Magnesium formulation: Verify patient is taking adequate dose (400-600mg daily) 2

Treatment Algorithm for Refractory Tension-Type Headaches

First-Line Addition: Amitriptyline

• Starting dose: 10mg at bedtime 4
• Titration: Increase by 10-25mg weekly as tolerated 4
• Target dose: 30-150mg daily (typically 50-100mg) 2, 4
• Mechanism: Provides analgesic effects independent of antidepressant action
• Timing: May take up to 30 days for full therapeutic effect 4

Acute Treatment Options

• Add appropriate acute medications:
  • Ibuprofen 400mg or acetaminophen 1000mg for breakthrough headaches 1
  • Consider aspirin-acetaminophen-caffeine combination for more severe episodes 2

If Inadequate Response After 6-8 Weeks

Option 1: Non-Pharmacological Approaches

• Cognitive-behavioral therapy
• Biofeedback
• Regular aerobic exercise
• Stress management techniques
• Sleep hygiene optimization

Option 2: Consider Other Preventive Medications

• Venlafaxine (75-150mg daily)
• Mirtazapine (15-30mg daily)
• Angiotensin receptor blockers (candesartan)

Option 3: Procedural Interventions

• Note: Botulinum toxin injections are specifically NOT recommended for tension-type headaches 1, 5
• Greater occipital nerve blocks may be considered if features of both migraine and tension-type headache are present 1

Important Caveats

1. Triptans are ineffective for pure tension-type headaches - they are migraine-specific medications and should be discontinued if the diagnosis is confirmed as tension-type headache 6

2. Medication overuse must be addressed - if patient is using acute medications (including triptans) more than 10-15 days/month, this may perpetuate headaches

3. Rule out secondary causes - although labs and blood pressure are normal, consider:

   • Cervical pathology
   • Temporomandibular joint dysfunction
   • Sleep disorders (especially sleep apnea)
   • Psychiatric comorbidities (depression, anxiety)

4. Headache diary importance - Have patient track:

   • Headache frequency, intensity, duration
   • Medication use
   • Potential triggers (stress, sleep disturbance, meals)
   • Response to treatments

Monitoring and Follow-up

• Reassess in 4-6 weeks after initiating amitriptyline
• Monitor for side effects: dry mouth, constipation, sedation, weight gain
• Elderly patients may require lower doses due to increased plasma levels 4
• If no response after adequate trial of amitriptyline (8-12 weeks at therapeutic dose), consider referral to headache specialist

Remember that tension-type headaches that are daily and refractory to multiple treatments may represent a more complex headache disorder requiring specialized management.