Chronic Tension-Type Headache Management Guidelines
First-Line Treatment Recommendation
Start amitriptyline as the primary preventive medication for chronic tension-type headache, combined with aerobic exercise or progressive strength training, and use NSAIDs (ibuprofen 400-800mg) or acetaminophen (1000mg) for acute breakthrough episodes. 1, 2
Acute Treatment Strategy
Preferred Medications
- Ibuprofen 400-800mg is first-line for acute episodes 2
- Acetaminophen 1000mg serves as an alternative when NSAIDs are contraindicated 2
Critical Pitfall to Avoid
- Limit simple analgesics to fewer than 15 days per month to prevent medication overuse headache, which significantly worsens outcomes and prevents effectiveness of preventive treatments 2
- Patients using acute medications more than 4 days per week are perpetuating their headaches and need immediate intervention 3
Preventive Treatment Algorithm
First-Line Preventive Therapy
Amitriptyline is the first-choice preventive medication with documented efficacy of approximately 40-50% 2
- Start slowly and titrate to therapeutic tolerated dose over 3 months for an adequate trial 2
- Combined with stress management therapy, amitriptyline produces clinically significant (≥50%) reductions in headache index scores in 64% of patients, compared to 38% with medication alone 4
Second-Line Preventive Options (if first-line fails or is not tolerated)
- Mirtazapine or venlafaxine are suggested alternatives 1, 2
- Venlafaxine is weight neutral and helpful with comorbid depression symptoms 2
- Valproate may be considered as an alternative preventive option 3
Medications to Explicitly Avoid
- Do NOT use botulinum toxin injections for chronic tension-type headache prevention 1, 3
- Do NOT use gabapentin based on lack of efficacy evidence and potential for misuse 3
Non-Pharmacological Interventions
Strongly Recommended
- Physical therapy delivered by a physical therapist receives a "weak for" recommendation and is beneficial 5, 2, 3
- Combination techniques include thermal methods, trigger point massage, and mobilization/manipulation 5
- Aerobic exercise or progressive strength training for prevention 5, 1, 2, 3
Insufficient Evidence (Cannot Recommend For or Against)
- Biofeedback and smartphone-based heart rate variability monitoring 5, 1
- Cognitive-behavioral therapy 5, 1
- Mindfulness-based therapies 5, 1
- Progressive muscle relaxation (when not combined with another intervention) 5, 1
- Acupuncture, dry needling, or yoga 1
- Dietary trigger avoidance 1
Limited Evidence for Spinal Manipulation
- Spinal manipulation was associated with moderate improvement in short-term pain and small improvement in function versus usual care, though evidence has serious methodological limitations 5
Essential Lifestyle Modifications
- Maintain regular lifestyle patterns: consistent sleep schedule, regular meals, adequate hydration 2
- Limit caffeine intake 2
- Regular exercise program 2
- Good sleep hygiene 2
Treatment Monitoring
Require patients to maintain a headache diary to accurately track headache frequency, severity, and medication use, as patients cannot reliably report headache frequency without documentation 1
Indications for Initiating Prophylactic Treatment
- Two or more disabling attacks per month producing disability lasting 3+ days 1
- Acute medication use more than twice weekly, creating risk for medication-overuse headache 1
- Contraindication to or failure of acute treatments 1
- Patients with reduced quality of life between attacks despite less frequent headaches may also benefit 1
Procedural Interventions
Greater occipital nerve blocks are suggested for short-term treatment with a "weak for" recommendation 3
Key Clinical Reasoning Points
The pathogenesis involves both peripheral mechanisms (myofascial nociception) and central mechanisms (sensitization and inadequate endogenous pain control), with peripheral mechanisms predominating in episodic forms and central mechanisms predominating in chronic tension-type headache 6, 7. This explains why combined therapy (amitriptyline plus stress management) is more effective than monotherapy 4, as it addresses both peripheral and central sensitization pathways.
Patients with lower degrees of sensitization benefit more from manual therapies, while those with significant central sensitization require strategies directed at normalizing central nervous system sensitivity 8. This underscores the importance of combining pharmacological approaches (amitriptyline for central sensitization) with physical interventions (exercise, physical therapy for peripheral mechanisms) 2, 4.