What treatment options are available for chronic tension headaches unresponsive to Topiramate (topiramate) and Elavil (amitriptyline), with minimal relief from Celebrex (celecoxib) and Mobic (meloxicam)?

Treatment Options for Chronic Tension Headaches Unresponsive to Topiramate and Amitriptyline

For patients with chronic tension headaches unresponsive to topiramate and amitriptyline, with minimal relief from NSAIDs like celecoxib and meloxicam, greater occipital nerve blocks should be considered as the next treatment option. 1

Pharmacological Options

First-Line Abortive Treatments

• Ibuprofen (400 mg) or acetaminophen (1000 mg) are recommended for short-term treatment of tension-type headache episodes 1, 2
• These medications may provide relief for breakthrough headaches even when preventive treatments have failed 2

Alternative Preventive Medications

• Consider SSRI antidepressants such as paroxetine as an alternative when amitriptyline has failed, particularly in patients who previously responded to placebo 3
• Valproate may be considered as an alternative preventive option with a "weak for" recommendation based on recent evidence 1
• Memantine has shown efficacy for prevention of episodic migraine and may be worth considering for tension-type headache that has failed standard therapies 1

Medications to Avoid

• Botulinum toxin injections (onabotulinumtoxinA or abobotulinumtoxinA) are specifically not recommended for chronic tension-type headache prevention 1
• Gabapentin is not recommended based on lack of efficacy evidence and potential for misuse 1

Procedural Interventions

Nerve Blocks

• Greater occipital nerve blocks are suggested for short-term treatment of headache with a "weak for" recommendation 1
• This intervention may be particularly valuable when pharmacological options have failed 1

Other Interventions

• Consider referral for complementary therapies that have shown some benefit in chronic tension-type headache patients:
  • Chiropractic treatment 4
  • Acupuncture 4
  • Massage therapy 4
• Be aware that only about 41% of patients perceive these complementary therapies to be beneficial 4

Treatment Algorithm

1. Confirm diagnosis and rule out medication overuse headache

   • Ensure patient is not overusing acute medications (>4 days/week) which can perpetuate headaches 1

2. Optimize abortive therapy

   • Ensure proper dosing of ibuprofen (400 mg) or acetaminophen (1000 mg) for acute episodes 1, 2

3. Consider procedural intervention

   • Greater occipital nerve block for short-term relief 1

4. Try alternative preventive medication

   • Consider paroxetine if amitriptyline failed 3
   • Consider valproate with appropriate monitoring 1
   • Consider memantine as an alternative option 1

5. Evaluate for comorbidities

   • Assess for psychiatric disorders which may affect treatment response 4
   • Address sleep disturbances which may exacerbate headaches 1

Important Considerations

• Patients with chronic tension-type headache often explore both conventional and complementary therapies due to inadequate relief from standard treatments 4
• Nearly 60% of patients don't inform their physicians about complementary treatment use, highlighting the importance of specifically asking about these treatments 4
• The presence of psychiatric comorbidities may predict greater likelihood of seeking alternative treatments 4
• When standard preventive medications fail, procedural interventions like nerve blocks may provide relief while exploring other pharmacological options 1