What are the recommended first-line treatments for tension headache prophylaxis?

Tension Headache Prophylaxis

Amitriptyline is the first-line pharmacological treatment for chronic tension-type headache prophylaxis, combined with aerobic exercise or progressive strength training as non-pharmacological interventions. 1

First-Line Treatment Approach

Start with amitriptyline as the primary prophylactic medication while simultaneously implementing lifestyle modifications including regular sleep schedules, consistent meal timing, and structured exercise programs. 1 The American College of Physicians specifically endorses amitriptyline as first-line therapy based on the strongest available evidence. 1

Amitriptyline Dosing and Efficacy

• Begin amitriptyline at low doses and titrate gradually upward to reach the recommended daily dose (typically up to 100 mg/day), adjusting based on patient tolerance. 2, 3
• This tricyclic antidepressant has been validated in multiple double-blind, placebo-controlled studies specifically for tension-type headache prophylaxis. 4
• Combined therapy with amitriptyline plus stress management produces clinically significant reductions (≥50% improvement) in 64% of patients, compared to 38% with medication alone. 3
• Expect to see therapeutic effects within 2-3 months; maintain treatment for 6-12 months before attempting dose reduction. 2

Non-Pharmacological First-Line Interventions

Aerobic exercise or progressive strength training should be prescribed concurrently with pharmacological therapy. 1 These interventions have documented efficacy and should not be considered optional add-ons but rather essential components of the treatment plan. 1

Physiotherapy is also recommended for tension-type headache management and can be integrated into the overall treatment strategy. 1

Second-Line Options

If amitriptyline is ineffective or not tolerated after an adequate trial (2-3 months at therapeutic doses):

• Consider mirtazapine or venlafaxine as alternative antidepressants with documented efficacy. 1, 4
• Intensify non-pharmacological interventions by adding or increasing physiotherapy and exercise programs. 1
• Other medications with weaker evidence include gabapentin, topiramate, and tizanidine. 4

What NOT to Use

Do not use botulinum toxin injections for chronic tension-type headache prophylaxis - the American College of Physicians explicitly recommends against this intervention. 1 This is a critical distinction from chronic migraine, where botulinum toxin is FDA-approved and effective. 5

Avoid IgG antibody testing for dietary trigger avoidance as there is insufficient evidence supporting this approach. 1

Treatment Monitoring and Duration

• Require patients to maintain a headache diary to accurately track headache frequency, severity, and medication use - patients cannot reliably report headache frequency without documentation. 5
• Assess treatment efficacy after 2-3 months of therapy at adequate doses. 2
• If treatment appears ineffective, verify medication compliance and check for analgesic overuse (≥15 days/month with NSAIDs or ≥10 days/month with triptans), as both can undermine prophylactic efficacy. 6, 2
• Continue successful prophylaxis for 6-12 months, then attempt gradual dose tapering to find the minimum effective dose or discontinue if possible. 2

Indications for Prophylactic Treatment

Initiate prophylaxis when patients experience:

• Two or more disabling attacks per month producing disability lasting 3+ days. 5
• Acute medication use more than twice weekly, which creates risk for medication-overuse headache. 5, 6
• Contraindication to or failure of acute treatments. 5
• Reduced quality of life between attacks despite less frequent headaches. 2

Common Pitfalls

• Failing to use adequate dosing before declaring treatment failure - tricyclic antidepressants require gradual titration to therapeutic levels. 2
• Not recognizing medication-overuse headache - frequent use of acute medications (NSAIDs ≥15 days/month, triptans ≥10 days/month) perpetuates chronic headache patterns. 6
• Premature discontinuation - prophylactic medications require 2-3 months to demonstrate full efficacy. 2
• Ignoring non-pharmacological interventions - exercise and stress management therapy provide additive benefits and should be prescribed routinely, not as afterthoughts. 1, 3

Insufficient Evidence

The following interventions lack sufficient evidence for routine recommendation: biofeedback, heart rate variability monitoring, cognitive-behavioral therapy, mindfulness-based therapies, progressive muscle relaxation, acupuncture, dry needling, and yoga. 1 However, stress management therapy combined with medication has proven superior to either alone. 3