What is the best course of treatment for a patient with chronic tension-type headaches or migraines that occur almost daily, are relieved by paracetamol (acetaminophen), worsened by stress and emotional distress, and improved with massage therapy?

Management of Chronic Daily Headache with Stress Triggers

This patient requires prophylactic medication with amitriptyline as first-line therapy, combined with stress management interventions, while immediately discontinuing daily paracetamol to prevent medication-overuse headache.

Critical First Step: Address Medication Overuse

• Stop daily paracetamol immediately – using analgesics more than twice weekly places patients at high risk for progression to chronic daily headache and perpetuates the headache cycle 1
• Medication overuse occurs in up to 73% of patients with chronic migraine and is a major barrier to successful treatment 2
• The pattern of near-daily paracetamol use is likely contributing to headache chronification and must be addressed before prophylaxis can be effective 2

Establish the Diagnosis

Start a headache diary immediately to document:

• Frequency (likely ≥15 days per month based on "almost every day") 2
• Duration of each episode 2
• Severity and character (bilateral tightness vs. unilateral throbbing) 1
• Associated symptoms (nausea, photophobia, phonophobia) 2
• Medication use patterns 2

Key diagnostic features from history:

• Stress and emotional triggers strongly suggest tension-type headache or migraine with tension-type features 1
• Relief with massage points toward muscular/tension component 1
• Response to simple analgesics (paracetamol) is consistent with either diagnosis 3
• If ≥15 headache days/month for ≥3 months, this meets criteria for chronic headache requiring prophylaxis 2

Prophylactic Treatment: The Evidence-Based Approach

Amitriptyline is the first-line prophylactic agent:

• Start 25 mg at bedtime, titrate to 50-100 mg as tolerated 2, 4
• Amitriptyline has the strongest evidence base for chronic tension-type headache prophylaxis 4
• Also effective for chronic migraine prevention 2
• Addresses both the headache and stress/emotional components 2
• Expected efficacy rate of 40-50% 5

Important counseling points:

• Anticholinergic side effects (dry mouth, constipation, drowsiness) are common 2
• Sedation can be beneficial given stress component – take at bedtime 4
• Full therapeutic effect requires 2-3 months of treatment 4
• Avoid in patients with cardiac conduction abnormalities or significant cardiovascular disease 2

Alternative prophylactic options if amitriptyline fails or is contraindicated:

• Topiramate 50-100 mg daily has the strongest evidence specifically for chronic migraine among oral agents 2, 6
• Beta-blockers if comorbid hypertension exists 4

Non-Pharmacologic Interventions (Essential Component)

Stress management is critical given the clear stress trigger:

• Behavioral interventions to modify response to stressful life events have demonstrated benefit 2
• Physical therapy, aerobic exercise, or progressive strength training for prevention 2, 4
• Relaxation therapies with EMG biofeedback have 40-50% efficacy rate, equivalent to tricyclics 5
• Massage therapy should be continued as it provides symptomatic relief 1

Acute Treatment Strategy (Once Prophylaxis Initiated)

Limit acute medication to ≤2 days per week maximum:

• Ibuprofen 400-800 mg is more effective than paracetamol for both tension-type and migraine headache 3, 5
• Naproxen 550 mg is an alternative NSAID with good evidence 3, 5
• Strict limit of twice weekly use to prevent medication-overuse headache 1, 5

Monitoring and Follow-Up

Evaluate treatment response at 2-3 months:

• Review headache diary to assess reduction in headache days 2, 4
• Assess for medication-overuse headache development 4
• Adjust prophylactic dose or consider alternative if inadequate response 4

Red flags requiring urgent evaluation (rule out before assuming primary headache):

• New onset after age 50 years 7
• Sudden-onset "thunderclap" pattern 6, 4
• Progressive worsening despite treatment 6, 4
• Neurological deficits 6, 4
• Headache awakening from sleep 6, 4

Specialist Referral Indications

• Uncertain diagnosis after initial evaluation 7, 4
• Poor response to initial prophylactic therapy after 2-3 months 4
• Consideration of onabotulinumtoxinA (Botox) if chronic migraine confirmed – this is the only FDA-approved therapy specifically for chronic migraine prophylaxis 2, 6

Critical Pitfalls to Avoid

• Never allow continued daily analgesic use – this perpetuates the chronic headache cycle 1, 5
• Do not treat frequent headaches with frequent acute medications; prophylaxis is mandatory 3
• Set realistic expectations: prophylaxis reduces frequency and severity but rarely eliminates all headaches 2
• Monitor for treatment-emergent depression or suicidal ideation with amitriptyline 2