How to prevent tension headaches?

How to Prevent Tension Headaches

For chronic tension-type headache prevention, start amitriptyline as first-line medication combined with aerobic exercise or progressive strength training 2-3 times weekly, while implementing essential lifestyle modifications including regular sleep schedule, consistent meals, adequate hydration, and limiting caffeine intake. 1, 2

When to Initiate Preventive Treatment

Consider prophylaxis when patients experience:

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

Require patients to maintain a headache diary to accurately track frequency, severity, and medication use, as patients cannot reliably report headache frequency without documentation 2

First-Line Pharmacological Prevention

Amitriptyline is the first-choice preventive medication with documented efficacy of approximately 40-50% 1, 2:

• Start slowly and titrate to therapeutic tolerated dose over 3 months for adequate therapeutic trial 1
• This recommendation is supported by multiple double-blind, placebo-controlled studies 3

Alternative Preventive Medications (Second-Line)

If amitriptyline is ineffective or not tolerated 2:

• Mirtazapine as alternative antidepressant 1, 2
• Venlafaxine (weight neutral and helpful with comorbid depression symptoms) 1, 2
• Valproate may be considered with appropriate monitoring (weak recommendation) 4

Avoid these medications:

• Botulinum toxin injections are specifically NOT recommended for chronic tension-type headache 2, 4
• Gabapentin lacks efficacy evidence and has potential for misuse 4

Non-Pharmacological Interventions (Essential Component)

Exercise Programs

Aerobic exercise or progressive strength training 2-3 times per week for 30-60 minutes 1, 2:

• Upper-body progressive strength training typically done 3 times weekly for 30 minutes, supervised 1
• Moderate quality evidence supports exercise as effective therapy for reducing pain intensity, frequency, and duration 5

Physical Therapy

Physical therapy delivered by a physical therapist using combination techniques 1, 4:

• Thermal methods, trigger point massage, and mobilization/manipulation 1
• Moderate evidence quality supports this as adjunctive therapy 4
• Trigger point therapy (dry needling, ischemic compression, positional relaxation techniques) has reduced headache duration, intensity, and frequency 6

Limited Evidence Interventions

Insufficient evidence to recommend for or against 2:

• Biofeedback and heart rate variability monitoring
• Cognitive-behavioral therapy
• Mindfulness-based therapies
• Progressive muscle relaxation
• Acupuncture, dry needling, or yoga
• Dietary trigger avoidance (do NOT use IgG antibody tests) 2

Essential Lifestyle Modifications

Implement these foundational changes 1:

• Limit caffeine intake
• Ensure regular meals and adequate hydration
• Maintain consistent sleep schedule and good sleep hygiene
• Regular exercise program

Treatment Algorithm

Step 1: Confirm Diagnosis and Rule Out Medication Overuse

• Ensure patient is not overusing acute medications (>4 days/week or >15 days/month), which perpetuates headaches 1, 4
• Limit simple analgesics to fewer than 15 days per month to prevent medication overuse headache 1

Step 2: First-Line Treatment

Lifestyle modifications + amitriptyline 2:

• Maintain regular lifestyle (sleep, meals, exercise)
• Start amitriptyline with slow titration over 3 months

Step 3: Add Non-Pharmacological Interventions

• Initiate aerobic exercise or progressive strength training program 1, 2
• Consider physical therapy with trigger point techniques 1

Step 4: Second-Line Treatment (if first-line fails)

• Consider mirtazapine or venlafaxine 2
• Intensify non-pharmacological interventions (physiotherapy, exercise) 2

Step 5: Additional Considerations

• Greater occipital nerve blocks for short-term relief (weak recommendation) 4
• Evaluate for comorbidities including psychiatric disorders and sleep disturbances 4

Critical Pitfalls to Avoid

• Do NOT use botulinum toxin for chronic tension-type headache (unlike chronic migraine where it is FDA-approved) 2, 4
• Limit acute medication use to prevent medication-overuse headache, which significantly worsens outcomes and prevents effectiveness of preventive treatments 1
• Do NOT rely on patient recall for headache frequency—always require a headache diary 2
• Avoid gabapentin due to lack of efficacy and misuse potential 4