What is the treatment for chronic tension headaches?

Treatment of Chronic Tension Headaches

For chronic tension-type headache, initiate amitriptyline as the first-line preventive medication, starting at 10-25 mg at bedtime and titrating gradually to 50-100 mg as needed, while using ibuprofen 400 mg or acetaminophen 1000 mg for breakthrough episodes. 1, 2, 3

Preventive Pharmacotherapy

Amitriptyline is the cornerstone of chronic tension headache prevention and should be started in all patients with frequent headaches (>15 days per month). 1, 3

• Start at 10-25 mg at bedtime to minimize side effects 1, 4
• Titrate gradually by 10-25 mg increments every 1-2 weeks 1
• Target dose is typically 50-100 mg at bedtime, though some patients may require up to 150 mg 3, 4
• Therapeutic effect may take up to 30 days to develop 4
• Monitor specifically for anticholinergic effects (dry mouth, constipation, urinary retention, confusion) especially in elderly patients and those with cardiac comorbidities 3, 4

Alternative Preventive Options

If amitriptyline fails or is not tolerated:

• Valproate may be considered as a second-line option with weak supporting evidence 2
• Memantine has shown efficacy for episodic migraine and may be worth trying for refractory tension headaches 2

Medications to Avoid

• Do NOT use botulinum toxin (onabotulinumtoxinA or abobotulinumtoxinA) for chronic tension-type headache—it is specifically not recommended 2
• Avoid gabapentin due to lack of efficacy evidence and potential for misuse 2
• Avoid opioids due to high risk of dependence and medication overuse headache 1, 3

Acute/Breakthrough Treatment

For individual headache episodes despite preventive therapy:

• Ibuprofen 400 mg is first-line, showing significant pain-free response at 2 hours 1, 3
• Acetaminophen 1000 mg is equally effective as an alternative 1, 3
• Take medication early in the headache episode for maximum effectiveness 3
• If inadequate response, consider combination preparations with caffeine or alternative NSAIDs like naproxen sodium 550 mg 3, 5

Critical Medication Overuse Warning

Limit acute medication use to no more than 2 days per week to prevent medication overuse headache, which perpetuates the chronic headache cycle. 1, 2, 3 Using acute medications more than 4 days per week can worsen the overall condition and lead to transformation into chronic daily headache. 2, 6

Procedural Interventions

• Greater occipital nerve blocks may provide short-term relief with weak supporting evidence 2
• This is a reasonable option for patients needing temporary relief while waiting for preventive medications to take effect 2

Non-Pharmacological Approaches

These should be used as adjunctive therapy, not monotherapy:

• Physical therapy is suggested for management of tension-type headache 7, 3
• Aerobic exercise or progressive strength training for prevention 7
• Cognitive-behavioral therapy showed 56% reduction in headache index in one study, slightly superior to amitriptyline's 27% reduction 8

However, the evidence quality for non-pharmacological interventions is generally lower than for medications, and there is insufficient evidence to make strong recommendations for or against biofeedback, cognitive behavioral therapy, mindfulness, acupuncture, or yoga. 7, 3

Treatment Algorithm

1. Confirm diagnosis and rule out medication overuse headache (>4 days/week of acute medication use) 2

2. Initiate amitriptyline 10-25 mg at bedtime, titrate to 50-100 mg over 4-6 weeks 1, 3

3. Optimize acute therapy with ibuprofen 400 mg or acetaminophen 1000 mg, strictly limiting use to ≤2 days per week 1, 2

4. If inadequate response after 8-12 weeks at therapeutic amitriptyline dose, consider valproate or memantine 2

5. Consider greater occipital nerve block for short-term relief if needed 2

6. Add physical therapy and aerobic exercise as adjunctive measures 7

7. Evaluate for comorbidities including depression, anxiety, and sleep disturbances that may affect treatment response 2

Common Pitfalls

• Starting amitriptyline at too high a dose, leading to intolerable side effects and discontinuation 1, 4
• Allowing patients to overuse acute medications, which perpetuates the headache cycle 1, 2
• Expecting immediate results from amitriptyline—counsel patients that full effect takes up to 30 days 4
• Using botulinum toxin, which is ineffective for tension-type headache despite its efficacy in chronic migraine 2
• Prescribing opioids or butalbital-containing compounds, which increase risk of medication overuse headache and dependence 1, 3, 6