What is the treatment for chronic tension-type headaches in adolescents?

Treatment for Chronic Tension-Type Headaches in Adolescents

First-line treatment for chronic tension-type headaches in adolescents includes non-pharmacological approaches such as lifestyle modifications and stress management techniques, with amitriptyline (10-100 mg at night) recommended as a pharmacological option for those requiring preventive treatment. 1

Non-Pharmacological Management

Lifestyle Modifications

• Regular daily structure is crucial for managing chronic tension-type headaches:
  • Maintain regular sleep schedule
  • Ensure regular meal times
  • Stay adequately hydrated
  • Identify and avoid specific headache triggers 1, 2

Stress Management Techniques

• Relaxation training has shown significant efficacy in reducing headache frequency in adolescents 3
• Stress management therapy produces clinically meaningful reductions in headache activity 4
• Recommended techniques include:
  • Progressive muscle relaxation
  • Cognitive coping strategies
  • Biofeedback
  • Yoga 5

Physical Activity

• Low-intensity physical activity is beneficial for adolescents with tension-type headaches
• Regular exercise provides:
  • Increased overall well-being
  • Distraction from headache pain
  • Stress reduction 2

Pharmacological Management

Acute Treatment

• Simple analgesics are the mainstay of acute treatment:
  • Ibuprofen (7.5-10 mg/kg)
  • Acetaminophen (15 mg/kg) 1, 6
• Important cautions:
  • Avoid opioid analgesics due to dependency risk and rebound headaches
  • Limit use of butalbital-containing analgesics 1
  • Monitor for medication overuse headache with frequent analgesic use

Preventive Treatment

• Amitriptyline is a first-line preventive medication:

  • Starting dose: 10 mg at bedtime for adolescents
  • May gradually increase to 10-100 mg at bedtime as needed and tolerated 1, 7
  • Lower dosages are generally recommended for adolescents compared to adults 7
  • Monitor for side effects, particularly anticholinergic effects 7

• Other preventive options:

  • Propranolol (1-4 mg/kg/day)
  • Topiramate (50-100 mg daily) 1

Combined Approach

• The combination of pharmacological treatment and stress management therapy has shown superior efficacy (64% response rate) compared to either approach alone (35-38% response rate) 4

Monitoring and Follow-up

• Maintain a headache diary to track:

  • Frequency and severity of headaches
  • Potential triggers
  • Response to treatments 1

• Evaluate treatment response within 2-3 months after initiation or change in treatment 1

• Communicate realistic expectations to adolescents and parents:

  • Complete elimination of headaches is unlikely
  • The goal is reducing frequency, severity, and disability 1

Clinical Pitfalls to Avoid

• Overuse of analgesics can lead to medication overuse headache
• Tricyclic antidepressants like amitriptyline require careful dosing in adolescents - start low and increase gradually 7
• Monitor adolescents on antidepressants for suicidality as indicated in the boxed warning 7
• Don't neglect the importance of non-pharmacological approaches, which are effective and have fewer side effects than medications