Is preventative migraine medication effective for treating tension headaches?

Preventative Migraine Medications for Tension Headaches

Amitriptyline is the only preventive medication with proven efficacy for both migraine and tension-type headache, making it the clear first-line choice when treating patients with mixed or pure tension-type headaches. 1, 2

Evidence-Based Recommendation

Use amitriptyline 30-150 mg/day as first-line preventive therapy for tension-type headaches, particularly when patients have mixed migraine and tension-type headache features. 1, 2

Why Amitriptyline is Superior for Tension Headaches

• Amitriptyline is the only tricyclic antidepressant with consistent evidence from controlled trials demonstrating efficacy for mixed migraine and tension-type headache 1, 2
• Direct comparative trials show amitriptyline is superior to propranolol specifically for patients with mixed migraine and tension-type headache, while propranolol is more effective for pure migraine alone 1, 2
• Tricyclics have the strongest evidence as prophylactic therapy specifically for tension-type headache 3

Other Migraine Preventives Do NOT Work for Tension Headaches

Beta-blockers (propranolol, timolol, metoprolol) are effective only for pure migraine and should NOT be used for tension-type headaches. 1, 4

• Propranolol 80-240 mg/day has consistent evidence for migraine prevention but is specifically more effective for pure migraine, not mixed or tension-type headache 1, 4
• The evidence clearly distinguishes that propranolol loses superiority when tension-type features are present 1

Other migraine-specific preventives (topiramate, divalproex, anticonvulsants) lack evidence for tension-type headache treatment. 5, 6

Dosing Algorithm for Amitriptyline

1. Start low: Begin with 10-25 mg at bedtime 2
2. Titrate slowly: Increase gradually over weeks to months to minimize side effects 2
3. Target dose: Aim for 30-150 mg/day as tolerated 1, 2
4. Adequate trial: Continue for 2-3 months at therapeutic dose before declaring treatment failure 2

Managing Side Effects

• Common adverse events include drowsiness, weight gain, dry mouth, and constipation 2
• These anticholinergic symptoms are generally well-tolerated and seldom cause premature withdrawal 2
• Use caution in elderly patients due to increased anticholinergic risk 2

Critical Pitfalls to Avoid

Do not use propranolol or other beta-blockers for tension-type headache—they lack efficacy for this indication and the evidence specifically shows amitriptyline is superior when tension features are present. 1

Do not discontinue amitriptyline before 2-3 months of therapeutic dosing, as many clinicians stop treatment prematurely before true efficacy can be assessed. 2

Educate patients to limit acute medication use to prevent medication overuse headache, which worsens headache frequency and interferes with preventive treatment effectiveness. 2

• Avoid interfering medications like ergotamine during preventive treatment 1, 2
• Limit acute rescue medications to less than twice per week 1

When Preventive Therapy is Indicated

Initiate preventive therapy when patients have: 1, 5

• Two or more attacks per month producing disability lasting 3+ days per month 1
• Four or more headaches per month or eight or more headache days per month 5
• Contraindication to or failure of acute treatments 1
• Use of abortive medication more than twice per week 1