Is propranolol (beta blocker) indicated for tension-type headaches?

Propranolol for Tension-Type Headache

Propranolol is not indicated for tension-type headaches and should not be prescribed for this condition. 1

Evidence-Based Treatment Recommendations for Headaches

Tension-Type Headache Management

According to current guidelines, the recommended treatments for tension-type headaches include:

1. Non-pharmacological approaches:

   • Physical therapy (strongly recommended) 1
   • Thermal methods
   • Trigger point massage
   • Mobilization/manipulation techniques
   • Aerobic exercise (40 minutes, three times weekly) 1
   • Progressive strength training (2-3 times weekly for 30-60 minutes) 1
   • Cognitive-behavioral therapy (CBT) 1

2. Pharmacological management:

   • First-line: Simple analgesics and NSAIDs for episodic tension-type headache
   • For chronic tension-type headache: Tricyclic antidepressants, particularly amitriptyline 2

Beta-Blockers in Headache Management

Beta-blockers like propranolol are specifically indicated for migraine prevention, not tension-type headaches:

• Propranolol is recommended at doses of 80-240 mg/day for migraine prophylaxis 1
• Recent evidence confirms propranolol's effectiveness in migraine with moderate certainty evidence for reducing monthly migraine days and increasing the proportion of patients experiencing ≥50% reduction in monthly migraine days 3
• Propranolol is considered a first-line agent for migraine prevention along with timolol, amitriptyline, divalproex sodium, sodium valproate, and topiramate 4

Clinical Implications and Pitfalls

Important Distinctions

It's crucial to distinguish between migraine and tension-type headache when selecting treatment:

• Propranolol has established efficacy for migraine prophylaxis 5, 3
• For tension-type headache, tricyclic antidepressants (particularly amitriptyline) are the drugs of choice for prevention 2

Common Pitfalls to Avoid

1. Misdiagnosis: Ensure proper differentiation between migraine and tension-type headache before treatment selection
2. Inappropriate medication selection: Using migraine-specific preventives like propranolol for tension-type headaches is not evidence-based
3. Overlooking non-pharmacological approaches: Physical therapy and lifestyle modifications should be incorporated into tension-type headache management

Treatment Algorithm for Tension-Type Headache

1. Acute treatment:

   • Simple analgesics (acetaminophen)
   • NSAIDs

2. Preventive treatment (for chronic tension-type headache):

   • First-line: Amitriptyline
   • Consider: Other tricyclic antidepressants

3. Non-pharmacological approaches (should be implemented concurrently):

   • Physical therapy
   • Regular exercise
   • Stress management techniques
   • Cognitive-behavioral therapy

The evidence clearly shows that while propranolol is effective for migraine prophylaxis, it is not indicated for tension-type headaches, where amitriptyline and non-pharmacological approaches remain the standard of care.