What is the recommended initial management for tension‑type headache with occipital neuralgia presenting as muscle‑related pain at the insertion of the sternocleidomastoid, splenius, and upper trapezius?

Management of Tension-Type Headache with Occipital Neuralgia and Cervical Muscle Involvement

Start with physical therapy targeting the cervical spine and posterior neck muscles combined with ibuprofen 400 mg or acetaminophen 1000 mg for acute episodes, and initiate amitriptyline for prevention if headaches occur more than twice weekly. 1

Acute Episode Management

For immediate pain relief during acute episodes:

• Use ibuprofen 400 mg or acetaminophen 1000 mg as first-line treatment 2, 1
• Limit analgesic use to fewer than 2 days per week and less than 15 days per month to prevent medication overuse headache 1, 3
• Acetaminophen doses below 1000 mg (such as 500-650 mg) do not show statistically significant improvement 2

Physical Therapy and Rehabilitation (First-Line Non-Pharmacologic)

Physical therapy is specifically recommended for tension-type headache with cervical dysfunction and should be initiated immediately: 2, 1

• Target the cervical spine, posterior neck muscles (splenius, upper trapezius), and sternocleidomastoid insertion points 1
• Utilize combination techniques including thermal methods, trigger point massage, and mobilization/manipulation 3
• Consider extracorporeal shock wave therapy to bilateral trapezius muscles if myofascial trigger points are identified, as this has shown immediate pain relief in refractory cases 4

Exercise prescription:

• Aerobic exercise or progressive strength training 2-3 times per week for 30-60 minutes 2, 3
• Upper-body progressive strength training 3 times weekly for 30 minutes under supervision 3

Preventive Pharmacotherapy

Initiate amitriptyline when headaches occur more than twice per week or produce disability lasting 3+ days: 5, 1

• Start at low dose and titrate slowly to therapeutic tolerated dose over 3 months for adequate trial 3
• Efficacy rate approximately 40-50% 3
• Be aware of anticholinergic adverse effects, especially in older patients and those with cardiac comorbidities, plus overdose potential 2

If amitriptyline fails or is not tolerated:

• Consider mirtazapine or venlafaxine as second-line options 1, 3
• Venlafaxine is weight neutral and helpful with comorbid depression 3

Do NOT use botulinum toxin injections for chronic tension-type headache prevention - this has not shown statistically significant improvement in critical outcomes and receives a "weak against" recommendation 2, 5, 1

Interventional Options for Occipital Neuralgia Component

Greater occipital nerve block may be considered for short-term treatment: 2, 1

• This receives a "weak for" recommendation for short-term migraine treatment but has insufficient evidence for chronic prevention 2
• Duration of relief may be short-term 6
• OnabotulinumtoxinA injection may improve the sharp but not the dull component of occipital neuralgia pain 6

For refractory cases:

• Radiofrequency ablation and occipital nerve stimulation may provide effective long-term relief 6
• Transcutaneous electrical nerve stimulation (TENS) has shown significant pain relief in case reports, with conventional TENS 3 sessions per week 7

Treatment Algorithm

Step 1 - Initial Management:

• Confirm diagnosis and exclude medication overuse headache 1
• Assess for cervical dysfunction and myofascial trigger points at sternocleidomastoid, splenius, and trapezius insertions 1, 4
• Start physical therapy targeting cervical spine and posterior neck muscles 1
• Optimize acute treatment with ibuprofen 400 mg or acetaminophen 1000 mg (limit to <2 days/week) 1, 3
• Initiate aerobic exercise or progressive strength training program 1, 3

Step 2 - Add Prevention (if ≥2 disabling attacks/month):

• Start amitriptyline as prophylaxis 1, 3
• Continue physical therapy and exercise 1

Step 3 - If First-Line Fails:

• Intensify non-pharmacological interventions 1
• Consider mirtazapine or venlafaxine 1, 3
• Consider occipital nerve block for short-term relief 1
• If myofascial trigger points persist, consider extracorporeal shock wave therapy to trapezius muscles 4
• Consider TENS therapy 3 sessions per week 7

Step 4 - Refractory Cases:

• Radiofrequency ablation of occipital nerves 6
• Occipital nerve stimulation 6

Essential Lifestyle Modifications

Implement these concurrently with all treatment steps: 3

• Maintain consistent sleep schedule with good sleep hygiene 3
• Ensure regular meals and adequate hydration 3
• Limit caffeine intake 3
• Continue regular exercise program 3

Critical Pitfalls to Avoid

• Do not use analgesics more than 15 days per month - this creates medication overuse headache which significantly worsens outcomes and prevents effectiveness of preventive treatments 3
• Do not use botulinum toxin for tension-type headache - unlike chronic migraine where it is FDA-approved and effective, it does not work for chronic tension-type headache 5, 1
• Do not use acetaminophen doses below 1000 mg - lower doses (500-650 mg) lack statistically significant improvement 2
• Do not give up on amitriptyline too early - requires 3-month adequate therapeutic trial at tolerated dose 3