What is the best course of treatment for a patient with chronic tension-type headache?

Treatment of Chronic Tension-Type Headache

For chronic tension-type headache, initiate amitriptyline as first-line prophylactic therapy combined with stress management techniques, while using NSAIDs or acetaminophen for acute symptom relief, avoiding frequent analgesic use to prevent medication-overuse headache. 1, 2, 3

Initial Diagnostic Considerations

Before treating as primary tension-type headache, rule out secondary causes, particularly in specific populations:

• Any patient with "red flag" features requires urgent neuroimaging before treatment: thunderclap/sudden-onset headache, worsening when lying down or with Valsalva, focal neurological deficits, headache awakening patient from sleep, or progressively worsening pattern 4, 5, 6
• Patients over 50 years with new-onset chronic headache warrant lower threshold for neuroimaging (brain MRI preferred, or non-contrast head CT in acute setting), as migraine typically remits with age while secondary headaches increase substantially 6
• If neuroimaging is normal but subarachnoid hemorrhage suspected, perform lumbar puncture for CSF analysis 4

Prophylactic Treatment (First-Line)

Amitriptyline is the drug of first choice for chronic tension-type headache prophylaxis:

• Tricyclic antidepressants (amitriptyline specifically) have the strongest evidence base for preventing chronic tension-type headache 2, 3
• In a randomized controlled trial, amitriptyline (up to 100 mg/day) or nortriptyline (up to 75 mg/day) produced significant reductions in headache activity, analgesic use, and disability compared to placebo 3
• Avoid valproate in women of childbearing age due to teratogenic effects 4, 5

Alternative prophylactic options with weaker evidence:

• Mirtazapine and venlafaxine are second-choice medications 2
• Beta-blockers may be considered, particularly if comorbid hypertension exists 1
• The efficacy of prophylactic drugs is often limited and treatment may be hampered by side effects 2

Acute Symptom Management

For episodic exacerbations:

• NSAIDs (ibuprofen, naproxen) are more effective than placebo and acetaminophen for acute tension-type headache 2, 7
• Ibuprofen specifically shows fewer short-term side effects compared to other NSAIDs 7
• Acetaminophen is effective but less so than NSAIDs 7
• Avoid triptans, muscle relaxants, and opioids - these are not effective for tension-type headache 2
• Critical pitfall: Limit analgesic use to prevent medication-overuse headache, which develops with frequent/excessive use 2, 8

Non-Pharmacologic Therapies (Essential Component)

Stress management and behavioral interventions should be combined with medication:

• Combined therapy (tricyclic antidepressant + stress management) produces clinically significant ≥50% reduction in headache in 64% of patients, compared to 38% with medication alone and 35% with stress management alone 3
• The 2024 VA/DoD guidelines suggest physical therapy for management of tension-type headache 1
• The 2024 VA/DoD guidelines suggest aerobic exercise or progressive strength training for prevention 1
• EMG biofeedback has documented effect, though evidence shows inconsistent results across studies 2, 7
• Cognitive-behavioral therapy and relaxation training (including relaxation, cognitive coping, progressive muscle relaxation) are likely effective 2, 3
• Rajyoga meditation combined with medical treatment showed 99% headache relief versus 51% with medication alone in one trial, though this requires validation 9

Physical therapy and acupuncture:

• May be valuable options but lack robust scientific evidence for efficacy 2
• The 2024 VA/DoD guidelines note insufficient evidence to recommend for or against acupuncture or dry needling 1

Treatment Algorithm

Step 1: Rule out secondary causes (neuroimaging if red flags present, lower threshold if age >50) 4, 5, 6

Step 2: Initiate prophylactic therapy with amitriptyline (or nortriptyline if amitriptyline not tolerated) 2, 3

Step 3: Add stress management/behavioral therapy (relaxation training, cognitive coping techniques) - this combination is superior to either alone 3

Step 4: Provide acute medication (NSAIDs preferred, acetaminophen as alternative) with strict instructions to limit use to prevent medication-overuse headache 2, 7

Step 5: Incorporate exercise (aerobic exercise or progressive strength training) as preventive measure 1

Step 6: Consider physical therapy as adjunctive treatment 1

Monitoring and Follow-Up

• Encourage headache diary to track frequency, severity, and medication use 1
• Evaluate treatment response within 2-3 months after initiation or change of treatment 5
• Monitor for medication-overuse headache development (analgesic use >10-15 days/month) 2
• If no improvement or uncertain diagnosis, refer to headache specialist 1, 6

Special Populations

Older adults (>50 years):

• Exercise greater caution with medication side effects and drug interactions 6
• Poor evidence base exists for all headache drugs in older age groups 6
• Monitor cardiovascular risk if considering any vasoactive medications 6

Women of childbearing age:

• Absolutely avoid valproate due to teratogenic effects 4, 5
• Consider pregnancy plans when selecting prophylactic medication 5