Prophylactic Treatment for Frequent Episodic or Chronic Tension-Type Headache
Amitriptyline is the recommended prophylactic medication for patients with frequent episodic or chronic tension-type headache who prefer pharmacologic therapy over behavioral interventions. 1
Why Amitriptyline is the Correct Choice
The 2023 VA/DoD Clinical Practice Guideline specifically recommends amitriptyline for the prevention of chronic tension-type headache, while ibuprofen and acetaminophen are recommended only for acute (abortive) treatment, not prophylaxis. 1
Key Distinction: Prophylaxis vs. Acute Treatment
- Amitriptyline is suggested for prevention of chronic tension-type headache with a "weak for" recommendation. 1
- Ibuprofen (400 mg) and acetaminophen (1000 mg) are suggested for short-term (abortive) treatment of tension-type headache episodes, not for prevention. 1, 2, 3
This is a critical distinction: your patient needs prophylactic therapy to reduce headache frequency, not just acute symptom relief. 2, 3
Practical Implementation
Starting Amitriptyline
- Initial dose: 10-25 mg at bedtime 2, 3
- Target dose: Gradually titrate up to 50-100 mg as needed and tolerated 2, 3
- Monitoring: Watch for anticholinergic side effects (dry mouth, constipation, urinary retention, sedation) 2, 3
Evidence Supporting Amitriptyline
Research demonstrates that amitriptyline significantly reduces headache frequency, duration, and analgesic consumption in chronic tension-type headache, though it appears less effective in purely episodic forms. 4 Multiple expert reviews and guidelines consistently identify amitriptyline as the first-choice prophylactic drug for chronic tension-type headache. 5, 6, 7
Important Caveats
Medication Overuse Prevention
- Limit acute medications (ibuprofen, acetaminophen) to no more than 2 days per week to prevent medication-overuse headache. 2
- If your patient is already overusing analgesics (>4 days/week), this must be addressed as it can perpetuate the headache cycle. 3
When Ibuprofen/Acetaminophen Are Appropriate
These medications remain valuable for breakthrough headaches while on prophylactic therapy with amitriptyline. 2, 3 They should not be used as the primary prophylactic strategy.
Alternative Options if Amitriptyline Fails
If amitriptyline is not tolerated or ineffective, second-line prophylactic options include mirtazapine or venlafaxine. 5, 6 However, these are clearly second-choice agents.