Is topiramate (an antiepileptic) effective for treating chronic tension headaches?

Topiramate for Chronic Tension-Type Headache

Topiramate is NOT recommended for chronic tension-type headache, as it lacks high-quality evidence and guideline support for this indication. While topiramate has proven efficacy for chronic migraine prevention, the evidence for tension-type headache is limited to small, uncontrolled studies that do not meet the standard for definitive recommendations.

Evidence Quality and Guideline Support

• No major headache guidelines recommend topiramate for chronic tension-type headache 1, 2, 3
• The 2024 VA/DoD Clinical Practice Guideline for Headache Management does not include topiramate as a recommended treatment for tension-type headache 1
• The American Academy of Neurology guidelines focus topiramate recommendations exclusively on migraine prevention, not tension-type headache 2, 3

Limited Research Evidence

The only available evidence consists of small, open-label studies without placebo controls:

• One prospective open-label study (n=46 completers) showed reduction in headache frequency from 23.5 to 12.6 days per month at weeks 13-24, with 73% achieving 50% reduction 4
• A second small study (n=51) reported decreased headache days from 13.25 to 8.65 monthly 5
• Critical limitation: Both studies were open-label without blinding or placebo control, making them highly susceptible to bias and placebo effects 4, 5

Contrast with Chronic Migraine Evidence

Topiramate has robust evidence for chronic migraine (≥15 headache days/month with migraine features on ≥8 days):

• Multiple randomized, double-blind, placebo-controlled trials demonstrate efficacy at 100 mg/day 6, 7
• Topiramate is the only oral preventive medication with Level A evidence specifically for chronic migraine 1
• Guidelines recommend topiramate as first-line therapy for chronic migraine due to proven efficacy and lower cost 2, 3

Clinical Pitfalls to Avoid

• Do not confuse chronic migraine with chronic tension-type headache: These are distinct diagnoses requiring different treatment approaches 1
• Patients reporting "15+ headache days per month" may actually have chronic migraine if 8+ days have migraine features (throbbing, moderate-severe intensity, nausea, photophobia/phonophobia) 1, 3
• Many patients underreport migraine features and only mention their "severe headache days," missing the chronic migraine diagnosis 1

Recommended Approach for Chronic Tension-Type Headache

First, confirm the diagnosis is truly chronic tension-type headache and not chronic migraine:

• Use a headache diary to document frequency and characteristics over 4 weeks 3
• Specifically ask about migraine features on headache days (nausea, light/sound sensitivity, throbbing quality) 1
• If ≥8 days per month have migraine features, the diagnosis is chronic migraine, not tension-type headache 3

For confirmed chronic tension-type headache, evidence-based options include:

• Amitriptyline (tricyclic antidepressant) - though evidence is limited even for this agent 1
• Non-pharmacological approaches including cognitive-behavioral therapy, biofeedback, and stress management 1
• Address comorbid conditions such as depression, anxiety, sleep disorders, and medication overuse 1, 3

If topiramate is considered despite limited evidence:

• Recognize this is off-label use without guideline support
• Start at 25 mg daily and titrate by 25 mg weekly to target dose of 100 mg/day 4
• Counsel patients about common adverse effects: paresthesias (29%), fatigue (12%), cognitive slowing, and weight loss 6, 4
• Women of childbearing potential require effective contraception due to teratogenic risk 1
• Topiramate reduces oral contraceptive efficacy, requiring alternative contraception methods 1