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Tension-type headache in adults: Preventive treatment

Tension-type headache in adults: Preventive treatment
Literature review current through: Jan 2024.
This topic last updated: Apr 07, 2023.

INTRODUCTION — Tension-type headache (TTH) is characterized by a bilateral, nonthrobbing headache of a mild to moderate intensity, typically without other associated features. TTH is the most common headache and prevalent neurologic disorder in the population. Due to its high prevalence in the population, TTH causes a high degree of disability.

The preventive therapies of TTH in adults are reviewed here. Other aspects of TTH are discussed separately.

(See "Tension-type headache in adults: Etiology, clinical features, and diagnosis".)

(See "Tension-type headache in adults: Acute treatment".)

(See "Tension-type headache in children".)

APPROACH TO TREATMENT — The preventive therapy of TTH ranges from drugs to nonpharmacologic therapies such as behavioral and cognitive interventions.

Indication for preventive treatment — Prophylactic headache treatment is indicated if the headaches are frequent, long lasting, or account for a significant amount of total disability [1]. With respect to TTH, both the frequent episodic subtype (1 to 14 headache days a month) and chronic subtype (≥15 headache days a month) warrant prevention as they may be associated with significant disability, especially when accompanied by migraine, comorbid depression, or anxiety [2].

Many patients with TTH who have up to 10 headache days per month can manage headaches with acute therapies, such as acetaminophen and nonsteroidal anti-inflammatory drugs. However, preventive therapy may also be indicated when acute therapy fails or is inappropriate because of inadequate response, adverse events, overuse, or contraindications.

Goals of treatment — The goals of preventive therapy in TTH are reasonably extrapolated from those devised for migraine headache [1]. These include the following:

Reduce attack frequency, severity, and duration

Improve responsiveness to treatment of acute attacks

Improve function and reduce disability

To achieve benefit, prophylactic headache therapy requires a sustained commitment on the part of the patient and clinician [3]. It is important to address patient expectations and consider patient preferences when deciding between different preventive therapies. In addition, the patient should be informed of the rationale for a particular treatment, the expected benefits of therapy, the duration of treatment that will likely be needed to achieve improvement, and the possible and likely side effects.

Selection of therapies — Preventive treatment should be individualized. Frequent TTH may be difficult to treat, but an acceptable result can usually be obtained by pharmacologic, nonpharmacologic, or a combination of nonpharmacologic and pharmacologic treatments [4].

Many patients who present with TTH have disabling symptoms, warranting a trial of pharmacotherapy. In addition, nondrug management should also be considered for all patients with TTH even though the scientific evidence is sparse and contradictory [2]. A therapeutic effect may be attained simply by taking the problem seriously, particularly if the patient is worried that the headache is caused by a serious problem such as a brain tumor. Behavioral treatments may be particularly well-suited for patients with the following conditions [5]:

Those who prefer nonpharmacologic treatment

Those who have an insufficient response to, or poor tolerance of, pharmacologic treatments

Females who are pregnant, planning to become pregnant, or nursing

Those with a history of excessive use of analgesics or acute medications

Those who have significant stress or deficient stress-coping skills

PHARMACOLOGIC THERAPIES — A variety of pharmacologic therapies have been studied for the prophylactic treatment of TTH, as discussed in the sections that follow. Evidence of efficacy is limited and inconsistent [6], but perhaps is strongest for the tricyclic antidepressants such as amitriptyline. Other medications that may be useful include the antidepressants mirtazapine and venlafaxine, the anticonvulsants topiramate and gabapentin, and the muscle relaxant tizanidine. In contrast, the available evidence suggests that the selective serotonin uptake inhibitors are not effective for TTH prophylaxis.

Tricyclic antidepressants — Supporting evidence that tricyclics are beneficial for TTH comes from a 2017 meta-analysis [7]. At eight weeks compared with placebo in five trials, tricyclics reduced headache frequency (weighted mean difference -4.8 headaches per month, 95% CI -6.6 to -3.0) and analgesic medications use. However, the baseline headache frequency was approximately 21 headaches per month, so the benefit with tricyclics was considered moderate.

Tricyclic antidepressants are reuptake inhibitors of serotonin and noradrenaline, and these neurotransmitter interactions are the presumed mechanism of action for this class of drugs. Negative data regarding SSRIs suggest that other potential mechanisms, including inhibition of norepinephrine reuptake and antagonism of N-methyl-D-aspartate (NMDA) receptors, may be more likely to mediate the analgesic effect of tricyclics [8]. Amitriptyline also reduces pericranial muscle tenderness, leading to peripheral antinociception and inhibition of central sensitization [9,10]. Patients should be informed that amitriptyline is an antidepressant agent but has an independent action on pain [2]. The beneficial effect for TTH is not related to the presence of depression [11].

We suggest the use of amitriptyline for patients with frequent episodic TTH or chronic TTH. Exceptions include patients with obesity, bipolar disease, or cardiac conduction defects. This recommendation is best suited for patients who have a preference for pharmacologic treatment rather than behavioral or other nonpharmacologic therapies. Our recommendation is in agreement with 2010 guidelines from the European Federation of Neurological Societies for the treatment of TTH, which conclude that amitriptyline has a clinically relevant prophylactic effect in patients with chronic TTH and should be the drug of first choice [2].

It is difficult to reach firm conclusions on the relative efficacy of tricyclics versus other treatment modalities as there are relatively few comparative trials [7]. The utility of combined tricyclic and behavioral therapy for the treatment of chronic TTH is reviewed below. (See 'Combined behavioral and tricyclic therapy' below.)

Dosing and duration of therapy — We suggest the following principles to guide preventive drug therapy for TTH:

Start the drug at the lowest dose, and increase the dose gradually until therapeutic benefit is achieved, the maximum dose of the drug is reached, or side effects become intolerable.

Give the prophylactic medication an adequate trial in terms of duration and dosage. Benefit is often first noted only after four to six weeks of therapy [12,13]. In addition, benefit may continue to accrue for three months.

Avoid overuse of analgesic medications. Ongoing analgesic overuse must be eliminated, or preventive therapy will likely be ineffective.

Measure the effectiveness of therapy by use of a patient headache diary to track daily headache frequency and intensity.

Once effective, maintain drug therapy for at least three to six months. Thereafter, a slow taper off the medication can be performed [12].

With these principles in mind, we start amitriptyline at 10 to 12.5 mg nightly and increase the dose in 10 to 12.5 mg steps every two to three weeks as tolerated and as needed for sleep, until there is improvement in headache or until a maximum dose of 100 to 125 mg nightly is reached.

It is common for practitioners to initiate amitriptyline at 25 mg each night and increase the dose in 25 mg increments each week, but in the author's clinical experience, such a regimen is complicated by increased side effects and reduced adherence compared with the one outlined above.

Nortriptyline and protriptyline can be considered as alternative tricyclics if amitriptyline is poorly tolerated. The effects of these tricyclic medications on sleep, anxiety disorders, and body weight can guide the choice among them.

Amitriptyline is the most sedating, nortriptyline is mild to moderately sedating, while protriptyline is nonsedating and may be somewhat stimulating in some. Thus, protriptyline should be used cautiously for patients who have anxiety and panic disorders.

Amitriptyline and nortriptyline can cause weight gain, while protriptyline may cause weight loss [14].

Nortriptyline is manufactured in capsules only and therefore is initiated and titrated in 10 or 25 mg increments and it can usually be increased on a weekly basis. Protriptyline is usually started at 5 mg each morning and increased in 5 mg increments every week with a target dose of 20 mg each morning.

Tricyclic medications are associated with an increased risk of cardiac conduction abnormalities and arrhythmias. Before initiating treatment with any of the cyclic antidepressants, patients should be screened for cardiac conduction system disease, which precludes the use of these medications. We and others suggest that patients age 40 years and older have a baseline electrocardiogram (ECG) for this purpose. Patients younger than age 40 can be screened by history for evidence of cardiac disease. They do not require an ECG if the history is negative. Patients who have a normal ECG before starting a tricyclic antidepressant do not need additional ECG monitoring while on the antidepressant, unless symptoms arise suggestive of cardiac toxicity. (See "Tricyclic and tetracyclic drugs: Pharmacology, administration, and side effects", section on 'Cardiac evaluation'.)

Other antidepressants — Limited data from small randomized controlled trials suggest that mirtazapine (a noradrenergic and specific serotonergic antidepressant) and venlafaxine (a serotonin-norepinephrine reuptake inhibitor) may be effective for the treatment of chronic TTH in patients without depression.

In an eight-week trial involving 24 patients with chronic TTH, including subjects not responsive to amitriptyline, mirtazapine (15 to 30 mg daily) treatment was associated with a 34 percent lower area under the headache curve (the sum of the daily recordings of headache duration multiplied by headache intensity), the primary outcome measure, than placebo, and the difference was statistically significant [15]. In addition, mirtazapine treatment was associated with statistically significant reductions in headache intensity, duration, and frequency.

More patients treated with mirtazapine had sedation, dizziness, and weight gain than did patients receiving placebo, but the difference was not statistically significant. However, weight gain is a known side effect of mirtazapine, and the short duration of the trial may explain why the relationship did not achieve statistical significance.

In a 12-week trial involving 60 patients with TTH and more than five headaches a month at entry, treatment with extended-release venlafaxine (150 mg daily) was associated with a statistically significant reduction in days with headache, the primary outcome measure, compared with placebo (45 percent reduction versus 16 percent increase) [16]. However, there were no statistically significant differences between treatment groups on any of the secondary outcome measures. Adverse events, mainly gastrointestinal symptoms, were more frequent in the venlafaxine group.

These results appear promising, but are limited. Mirtazapine is markedly higher priced than amitriptyline while comparative cost-effectiveness research is lacking. We believe the effectiveness of mirtazapine and venlafaxine for TTH prevention requires further confirmation in larger trials before either can be recommended as a routine treatment. The 2010 European guidelines consider mirtazapine and venlafaxine to be drugs of second choice for the prophylactic treatment of chronic TTH [2].

Available evidence suggests that selective serotonin reuptake inhibitors are not effective for the treatment of TTH in patients without depression [12]. This conclusion is supported by a meta-analysis published in 2015, which found that SSRIs did not show any benefit compared with placebo for patients with TTH [17].

Anticonvulsants — Limited evidence suggests that topiramate and gabapentin may be beneficial for patients with chronic TTH.

Direct evidence of benefit for gabapentin in TTH prevention is lacking, but one randomized trial evaluated this drug in 95 patients with chronic daily headache, including 25 patients with TTH and 58 with a combination of TTH and migraine [18]. Treatment with gabapentin (2400 mg daily) was associated with a statistically significant improvement in headache-free days compared with placebo. The strength of this finding is limited by methodologic problems with the study, including failure to use an intention-to-treat analysis.

An open-label study of topiramate (initially 25 mg daily, then increased to 100 mg daily) in 51 patients with TTH reported a significant decline in headache frequency after three months of treatment [19].

Further evidence from randomized clinical trials is needed to clarify whether gabapentin and topiramate have a role in TTH prevention.

Tizanidine — There is limited and conflicting data regarding the effectiveness of tizanidine, a muscle relaxant and antispasticity agent, for the prophylaxis of TTH [20-23]. An early clinical trial of 37 females with chronic TTH found that tizanidine (6 to 18 mg daily) was more effective than placebo [20]. However, a larger trial of 185 patients with chronic TTH showed that tizanidine (6 or 12 mg modified release daily) was without benefit compared with placebo [21].

An open-label trial of 18 subjects with chronic TTH reported that combined treatment with tizanidine (4 mg daily for three weeks) and amitriptyline (20 mg daily for three months) led to faster reduction in headache frequency, intensity, and duration than amitriptyline alone [24]. The small size and open-label nature of this trial precludes definitive conclusions.

Local injection treatments

Trigger point injections – Trigger point injections require more research, but limited data from small randomized controlled trials suggest that lidocaine injections may reduce headache frequency and, thereby, total acute medication use for patients with frequent episodic or chronic TTH [25,26].

Botulinum toxin injections – In a 2023 meta-analysis, 11 placebo-controlled trials evaluated onabotulinumtoxinA (botulinum toxin type A) for patients with chronic TTH [27]. Quality of evidence was low to moderate. Botulinum toxin injections led to a small reduction in the frequency, duration, and intensity of headaches, as well as lower use of acute pain medications. However, the absolute response rate with botulinum toxin injections was 12 percent, suggesting benefit of this therapy for unselected patients with TTH may only benefit a minority of patients. Given these data, the use of botulinum toxin injections for the preventive treatment of TTH is of uncertain benefit.

BEHAVIORAL THERAPIES — The goal of behavioral treatments is to prevent headaches by identifying and defusing headache triggers, which are particularly important in TTH, and by using self-regulation to modulate involuntary and subconscious physiologic processes [28]. Behavioral treatments for headache include the following methods [5,28,29]:

Regulation of sleep, exercise, and meals

Cognitive-behavioral therapy

Relaxation

Biofeedback

Combinations of the above (eg, stress management therapy often consists of a combination of behavioral methods, with an emphasis on cognitive-behavioral therapy)

Identifying the triggering or exacerbating factors for headache may be important for success in headache therapy. Epidemiologic studies suggest that stress and mental tension are the most frequent identified triggers for TTH [30]. Coping with headache triggers is probably a more valuable strategy than advice to avoid the triggers [31]. Since there is an important behavioral component to nearly all of the known headache triggers, behavioral therapies are a potentially useful means of coping with and/or alleviating these triggers [5].

A 2009 review of randomized trials evaluating behavioral treatments for chronic TTH included 44 trials with 2618 patients, but only five studies were considered to have low risk of bias [32]. Most trials lacked adequate statistical power, and rates of recovery or improvement frequently failed to reach clinical relevance. In 11 studies, biofeedback was compared with waitlist conditions, and in eight studies, relaxation treatment was compared with waitlist conditions, both showing inconsistent results.

First-line therapies — We suggest treatment using biofeedback combined with relaxation therapy rather than other behavioral therapy options for patients with frequent episodic TTH or chronic TTH. This recommendation is similar to the conclusions of the 2010 European guidelines for the treatment of TTH, which observed that there is no convincing evidence to support an effect of cognitive-behavioral therapy and relaxation training alone for TTH [2].

A 2008 meta-analysis of biofeedback for TTH included 53 studies and concluded that biofeedback was more effective than headache monitoring, placebo, and relaxation therapies [33]. In addition, the effect was long-lasting and enhanced by combination with relaxation therapy [2,33].

Nevertheless, cognitive-behavioral or combination therapies may be beneficial for patients with TTH who have underlying behavioral triggers or those who do not respond to other treatments. (See 'Alternative options' below.)

Biofeedback — Biofeedback methods are based upon the notion that an individual can learn to control involuntary and subconscious physiologic processes when information about these processes is fed back in the form of a visual or auditory signal [28]. Electromyography feedback is the predominant method used in TTH treatment.

Pericranial muscle tenderness is often associated with TTH, but many patients are either not aware of the relationship, or overly fixate on its importance. Biofeedback may be helpful in either circumstance.

Relaxation — Relaxation techniques are based upon the premise that an unwanted outcome, such as headache, can be diminished or avoided by altering physiologic responses and decreasing sympathetic arousal [28]. Various forms of relaxation include progressive muscle relaxation, autogenic training (ie, learning self-statements that suggest warmth and heaviness), meditative or passive relaxation, and self-hypnosis.

Alternative options

Cognitive-behavioral therapy — Cognitive-behavioral therapy combines principles of cognitive therapy, which teaches patients to identify, evaluate, and better respond to their dysfunctional thoughts and beliefs, and behavior therapy, which helps patients develop new and adaptive ways of behaving.

As applied to headache, cognitive-behavioral therapy attempts to modify a maladaptive response (eg, headache) to stressful events by altering the usual interpretations, thoughts, and assumptions associated with such events [28]. Identifying headache triggers (whether physical, psychologic, or behavioral) and developing effective coping strategies are important aspects of this therapy.

Combined behavioral and tricyclic therapy — Although data are limited, behavioral therapy and tricyclic therapy appear to have equivalent modest effectiveness for the treatment of chronic TTH, while tricyclic therapy achieves benefit more rapidly. In addition, a combination of the two therapies may be superior to either alone.

Supporting evidence comes from a clinical trial that randomly assigned 203 patients with chronic TTH to one of four treatment arms: tricyclic antidepressant treatment, placebo, stress management plus placebo, or stress management plus tricyclic antidepressant [34].

Patients assigned to tricyclics received amitriptyline (12.5 mg to 100 mg nightly as tolerated); nortriptyline (25 mg to 75 mg nightly as tolerated) was substituted if amitriptyline was poorly tolerated or ineffective [34]. Stress management therapy consisted of the following elements: three one-hour teaching sessions and two telephone contacts with a psychologist or counselor, instruction manuals and audio tapes to guide home-based stress management skills, deep muscle relaxation training, and cognitive coping or problem-solving techniques to manage and prevent headache-related stress.

The following outcomes were reported [34]:

Compared with placebo, all three active treatments (tricyclic antidepressant, stress management plus placebo, or stress management plus tricyclics) were associated with similar, statistically significant improvements in the headache index (a measure of overall headache activity) at six months, the primary outcome measure.

The magnitude of benefit was modest for all active treatments; each reduced the number of days a month with a headache of moderate or greater severity by half (from approximately 14 to 7 days).

Tricyclic treatment was associated with a more rapid improvement in headache index scores than stress management alone.

Tricyclic treatment was also associated with significantly more adverse events, mainly dry mouth and drowsiness, than placebo treatment.

The proportion of patients who achieved a clinically significant (ie, ≥50 percent) reduction in headache index scores was higher in the combined stress management plus tricyclics treatment group than in the tricyclic only group (64 versus 38 percent), and the difference was statistically significant.

Given these data, and despite limited evidence supporting benefit, we suggest treatment with combined tricyclic antidepressant therapy plus stress management therapy for patients with frequent episodic TTH or chronic TTH, rather than treatment with tricyclics alone or behavioral therapy alone. This recommendation is best suited for patients who are willing to undergo both pharmacologic and nonpharmacologic treatments.

Self-management — Although there are few data, many experts believe that a behavioral self-management program is important to minimize disease progression in the preventive treatment of TTH [5]. A potential advantage of these methods is that they encourage greater responsibility on the part of the patient to engage in health promotion, while maintaining essential collaboration between patient and practitioner [5].

Self-management involves developing knowledge of headache triggers with attention to reducing these triggers. For headache in general, this process includes attention to sleep problems, lack of exercise, medication and caffeine overuse, stress related to life events, and any other obvious factors. For TTH in particular, the emphasis of self-management is focused on developing stress awareness and control.

Implementation — Behavioral treatments can be applied in a clinic-based format with sessions involving one-to-one contact between the patient and a psychologist or counselor [5]. Alternative formats for delivery of behavioral self-management techniques include small-group therapy and home-based (minimal-contact) treatment [5].

While some individuals can gain expertise through self-learning via commercially available videos or internet-based programs, current evidence supports professional application. Referral to a community-based pain psychologist is advised if the practitioner does not have access to readily available behavioral therapy resources.

OTHER NONPHARMACOLOGIC THERAPIES — Nonpharmacologic interventions for TTH include heat, ice, acupuncture, manual therapies (including osteopathic manipulation and massage), rest, and biofeedback.

Acupuncture — The available evidence regarding acupuncture for TTH suggests that any benefit is likely to be modest.

A meta-analysis updated in 2016 identified seven randomized trials with sham controls [35]. While there was a statistically significant benefit for the primary outcome, the proportion of patients who achieved a ≥50 percent reduction of headache frequency, the effect size was small; the quality of the evidence was moderate.

In one of the larger individual trials that used 42 trained physician acupuncturists [36] and enrolled 270 patients with chronic TTH, acupuncture treatment was associated with a statistically significant benefit of fewer days with headache compared with no treatment (ie, wait list controls), but acupuncture was not beneficial compared with minimal (sham) acupuncture [37]. This result suggests that treatment with any acupuncture technique may have measurable therapeutic effects [36].

Although of limited benefit for the prevention of TTH, acupuncture is safe and may be used for patients who do not tolerate or desire more effective treatments such as amitriptyline.

Physical therapies — The benefit of physical therapy for TTH is unproven, though some studies suggest promise [38]. Various physical therapy methods, alone or in combination, have been used to treat TTH, including specific exercises, therapeutic heat or cold, massage, postural correction, therapeutic touch, traction, inactivation of muscle trigger points, spinal manipulation, and electrical therapies such as transcutaneous electrical nerve stimulation (TENS), electromagnetic therapy, ultrasound, and laser [2,39]. Osteopathic manipulative therapy uses a variety of techniques including massage, low velocity manipulations, and postural correction, depending on body area. Proposed methods for inactivating muscle trigger points include dry needling, ultrasound, laser, electrotherapy, and manual therapies [40,41]. However, the best technique is not yet defined, nor is it known if there is any particular subgroup of patients who are more likely to respond to this method.

Unfortunately, there are few high-quality randomized double-blind placebo-controlled trials evaluating the effectiveness of physical therapy for TTH prevention. The evidence is summarized by the following observations:

A 2014 systematic review identified six randomized controlled trials evaluating manual therapies that involved 249 subjects with TTH (mostly chronic TTH) [42]. One trial evaluated massage and five evaluated physiotherapy. Only two studies avoided co-intervention, leading to potential problems with bias and interpretation of the results.

In one of the larger trials included in the systematic review, 81 patients with TTH were randomly assigned to a program of craniocervical endurance exercises combined with standard physical therapy (massage, oscillation techniques, postural correction) or to physical therapy alone [43]. At six weeks, combined craniocervical training plus physical therapy was associated with a nonsignificant reduction in headache frequency compared with physical therapy alone, but the benefit was sustained, and the reduction in headache frequency was statistically significant at six months (1.95 fewer headaches per week, 95% CI 1.14-2.76). Furthermore, headache intensity and duration at six months were significantly reduced with combined treatment.

A meta-analysis identified five small randomized controlled trials that compared various multimodal manual therapies (eg, spine mobilization or manipulation, low-load stabilization exercises, soft tissue pressure release, and postural correction) with pharmacologic interventions [44]. In pooled data, manual therapies were associated with reduced headache frequency compared with pharmacologic therapies at two weeks; there was no significant difference at longer time points. Major limitations included lack of blinding (only one of the trials blinded assessors and none blinded therapists or subjects) and heterogeneity of the treatments.

In a single-blind randomized controlled trial pilot study of 40 subjects with frequent episodic TTH not on prophylactic regimens that randomly assigned patients to corrective osteopathic manipulative therapy or sham therapy, active treatment led to a significant improvement in headache frequency at one and three months, with an absolute reduction in headache frequency at three months of 33 percent [45].

A meta-analysis of three clinical trials found strength training produced a moderate improvement in pain intensity, but the certainty of these results was very low due to small number of patients assessed, risk of bias, and varied protocols used [46].

Given the lack of definitive evidence of benefit for physical therapy, its role in the preventive treatment of TTH remains unclear. However, these treatments are associated with a low risk of serious side effects [38,39]. We suggest treatment with physical therapy that includes craniocervical exercises for patients with frequent episodic TTH and chronic TTH who do not tolerate or desire more effective treatments such as amitriptyline and behavioral therapy.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Migraine and other primary headache disorders".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Beyond the Basics topics (See "Patient education: Headache treatment in adults (Beyond the Basics)".)

SUMMARY AND RECOMMENDATIONS

Indications for and approach to treatment – Prophylactic headache treatment is indicated if headaches are frequent, long lasting, or associated with a significant amount of disability. Preventive therapy may be also indicated when acute therapy fails or is inappropriate because of inadequate response, adverse events, overuse, or contraindications. (See 'Approach to treatment' above.)

Treatment should be individualized. Frequent tension-type headache (TTH) may be difficult to treat, but an acceptable result can usually be obtained by a combination of nonpharmacologic and pharmacologic treatments. (See 'Selection of therapies' above.)

Pharmacologic treatment options

Tricyclic antidepressants – For patients with frequent episodic TTH or chronic TTH who have a preference for pharmacologic treatment rather than behavioral therapy, we suggest tricyclic therapy with amitriptyline (Grade 2B). We start amitriptyline at 10 to 12.5 mg nightly and increase the dose in 10 to 12.5 mg steps every two to three weeks as tolerated and as needed for sleep, until there is improvement in headache up to a maximum dose of 100 to 125 mg nightly. Onset of benefit may be delayed until after four to six weeks of therapy. Once effective, we maintain medication therapy for three to six months prior to attempting a slow taper. (See 'Tricyclic antidepressants' above.)

Other pharmacotherapies – Other medications for TTH prophylaxis include serotonin-norepinephrine reuptake inhibitors (mirtazapine and venlafaxine) and anticonvulsants (gabapentin and topiramate). However, the benefit of these drugs for TTH prevention is not well established, and more clinical trial data are required. (See 'Other antidepressants' above and 'Anticonvulsants' above and 'Tizanidine' above.)

Behavioral treatments – For patients with frequent episodic TTH or chronic TTH who wish to avoid pharmacologic therapy, we suggest electromyography biofeedback combined with relaxation therapy (Grade 2B). Other behavioral treatment options include cognitive-behavioral therapy and regulation of sleep, exercise, and meals. (See 'Behavioral therapies' above.)

Combination therapy for patients with frequent headaches – For patients with frequent episodic TTH or chronic TTH, we suggest treatment with combined tricyclic antidepressant therapy plus stress management therapy rather than treatment with tricyclics alone or behavioral therapy alone (Grade 2B). (See 'Combined behavioral and tricyclic therapy' above.)

Other nonpharmacologic treatments – For patients with frequent episodic TTH and chronic TTH who do not tolerate or desire more effective treatments such as amitriptyline and biofeedback, we suggest treatment with acupuncture (Grade 2B) or physical therapy that includes craniocervical exercises, osteopathic manipulation therapy, or inactivation of muscle trigger points (Grade 2C). (See 'Other nonpharmacologic therapies' above.)

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Topic 3360 Version 25.0

References

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