Pregabalin for Tension-Type Headache
Pregabalin is not recommended for tension-type headache based on current evidence. The most recent and comprehensive guideline—the 2024 VA/DoD Clinical Practice Guideline for the Management of Headache—does not include pregabalin among recommended treatments for tension-type headache, and no clinical trials have established its efficacy for this indication 1.
Evidence-Based Treatment Recommendations for Tension-Type Headache
Preventive Therapy for Chronic Tension-Type Headache
Amitriptyline is the only medication with guideline support for preventing chronic tension-type headache (weak recommendation) 1. The typical dosing regimen is 30 to 150 mg/day, though the evidence base is limited 1.
- Botulinum toxin injections are specifically recommended against for chronic tension-type headache prevention (weak recommendation against) 1
- No other preventive agents, including pregabalin, gabapentin, or other anticonvulsants, have demonstrated efficacy in controlled trials for tension-type headache 1
Acute/Abortive Treatment for Tension-Type Headache
For short-term treatment of tension-type headache episodes, the VA/DoD guideline suggests 1:
- Ibuprofen 400 mg (weak recommendation)
- Acetaminophen 1000 mg (weak recommendation)
These simple analgesics remain first-line for episodic tension-type headache attacks 1.
Why Pregabalin Is Not Appropriate
Mechanism and Indication Mismatch
Pregabalin is a gabapentinoid that binds to the α2-δ subunit of voltage-gated calcium channels, reducing neurotransmitter release 2. This mechanism is effective for neuropathic pain (pain from nerve damage) but not for tension-type headache, which is a primary headache disorder without underlying nerve injury 3, 4.
Established indications for pregabalin include 5, 6, 3, 4:
- Postherpetic neuralgia (NNT 3.9-5.3 for substantial benefit at 300-600 mg/day)
- Painful diabetic neuropathy (NNT 7.8-22 for substantial benefit)
- Central neuropathic pain
- Fibromyalgia (though with higher NNTs of 11+)
Evidence Specifically Excludes Tension-Type Headache
Multiple systematic reviews of pregabalin for pain conditions have not identified any trials in tension-type headache 3, 4. One Cochrane review examining gabapentin and pregabalin for migraine prophylaxis found no evidence of efficacy even for that related headache disorder 7.
Common Pitfalls to Avoid
Do Not Confuse Tension-Type Headache with Neuropathic Pain
Tension-type headache presents as bilateral, pressing/tightening (non-pulsating) pain without the features of neuropathic pain such as burning, shooting, electric-shock quality, or allodynia 1. Prescribing pregabalin for tension-type headache exposes patients to significant adverse effects without evidence of benefit.
Adverse Effects Are Substantial
If pregabalin were prescribed off-label for tension-type headache, patients would face 5, 3, 4:
- Dizziness in 23-46% of patients (dose-dependent)
- Somnolence in 15-25%
- Peripheral edema in 10%
- Weight gain
- Fall risk, especially in elderly patients
The NNH (number needed to harm) for treatment discontinuation due to adverse events is approximately 5-7 patients at therapeutic doses 3, 4.
Alternative Approach for Mixed Migraine and Tension-Type Headache
If a patient has both migraine and tension-type headache, one older trial suggested that amitriptyline may be superior to propranolol for this mixed presentation 1. This represents the only scenario where the evidence base for tension-type headache overlaps with preventive pharmacotherapy, but even here, pregabalin has no established role 1.
Clinical Algorithm
For chronic tension-type headache requiring preventive therapy:
First-line: Amitriptyline 30-150 mg/day at bedtime 1
- Start low (10-25 mg) and titrate weekly
- Monitor for anticholinergic effects (dry mouth, constipation, drowsiness)
- Allow 4-8 weeks at therapeutic dose to assess efficacy
For acute episodes: Ibuprofen 400 mg or acetaminophen 1000 mg 1
- Limit use to avoid medication-overuse headache (≤2 days/week)
If pharmacotherapy fails: Consider behavioral interventions, stress management, physical therapy, or biofeedback—none of which are addressed by pregabalin 1
Pregabalin should not be prescribed for tension-type headache in routine clinical practice 1, 7.