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Tension-Type Headache: Management
Treatment of TTH depends on its frequency. Infrequent episodic TTH requires only simple analgesics as needed. Frequent episodic and chronic TTH benefit from preventive therapy, with amitriptyline as the only medication with strong evidence. Non-pharmacologic interventions — physical therapy, stress management, and EMG biofeedback — are central to management, particularly for chronic TTH where central sensitization limits the effectiveness of pharmacotherapy alone.
Prevention: Amitriptyline 25-75 mg at bedtime is the only preventive with Level A evidence for chronic TTH
MOH risk: Simple analgesics ≥15 days/month or combination analgesics ≥10 days/month — a major driver of chronic daily headache in TTH patients
Non-pharmacologic: EMG biofeedback (Level A), physical therapy, stress management/CBT, and postural correction should be part of every chronic TTH treatment plan
Triptans do not work for TTH — a helpful diagnostic and therapeutic distinction from migraine
Muscle relaxants (tizanidine, cyclobenzaprine) are sometimes used as adjuncts but have limited evidence
Acute Treatment
Agent
Dose
Evidence
Notes
Ibuprofen
400 mg
Level A. NNT ~3.2 for pain-free at 2 hours
Best-studied NSAID for TTH. GI precautions apply.
Aspirin
500-1000 mg
Level A. Effective at 1000 mg (NNT ~8 at 500 mg; ~3 at 1000 mg)
Effervescent formulation may have faster onset. GI side effects.
Acetaminophen
1000 mg
Level A. Effective but slightly less than ibuprofen in head-to-head comparisons
Preferred if GI or cardiovascular risk precludes NSAIDs. Hepatotoxicity with overuse.
Naproxen
375-550 mg
Level B. Longer half-life (12 hours); fewer studies than ibuprofen for TTH
Option for prolonged TTH episodes
Ketoprofen
25-50 mg
Level B. Positive RCTs
Available OTC in some countries. Effective alternative NSAID.
Counsel every patient with frequent TTH to limit acute medication to <10-15 days/month and to use a headache diary to track usage
If MOH develops, withdrawal of the overused medication is the first and most important treatment step
Preventive Treatment
When to Start Prevention
Frequent episodic TTH (≥4 days/month) with significant disability or impaired quality of life
Chronic TTH (≥15 days/month) — nearly all should be on preventive therapy
Risk of or established medication overuse (needing acute medications frequently)
Patient preference for a preventive strategy over as-needed treatment
Pharmacologic Prevention
Agent
Dose
Evidence
Notes
Amitriptyline
25-75 mg at bedtime
Level A (only Level A preventive for chronic TTH). Cochrane review: NNT ~3-4 for ≥50% improvement. Multiple positive RCTs.
Start 10 mg, titrate by 10 mg every 1-2 weeks. Target 25-50 mg for most patients. Sedation is the main limiting factor. Also beneficial if comorbid migraine or insomnia.
Nortriptyline
25-75 mg at bedtime
Consensus (no large RCTs for TTH specifically). Accepted as equivalent alternative to amitriptyline.
Less sedation, less anticholinergic effects. Preferred in elderly or patients sensitive to amitriptyline side effects.
Mirtazapine
15-30 mg at bedtime
Level B. Bendtsen et al. (2004): positive RCT for chronic TTH; 34% reduction in headache area-under-curve vs placebo
Alternative when TCAs not tolerated. Sedating (beneficial for insomnia). Weight gain. NaSSA mechanism (different from TCAs).
Venlafaxine ER
150 mg daily
Level B. Positive data extrapolated from chronic daily headache trials (mixed migraine/TTH populations)
Option when depression or anxiety coexists. Same considerations as in migraine prevention.
Tizanidine
2-8 mg at bedtime or divided BID
Limited. Saper et al. (2002): positive for chronic daily headache (mixed population). Not TTH-specific.
Alpha-2 agonist / muscle relaxant. Sedation is the main side effect. Can be used as adjunct to TCA. Monitor LFTs.
Topiramate
50-100 mg/day
Negative for TTH specifically. Positive mainly for migraine and chronic daily headache with migraine component.
Not recommended for pure TTH. May help if migraine component is present.
Amitriptyline for Chronic TTH: Prescribing Guide
Start: 10 mg at bedtime (lower starting dose reduces dropout from sedation)
Titrate: Increase by 10 mg every 1-2 weeks as tolerated
Target: 25-50 mg for most patients; up to 75 mg if needed
Onset: 2-4 weeks at target dose (faster onset than for migraine prevention)
Duration: Continue for at least 3-6 months after headache improvement. Then taper gradually (reduce by 10 mg every 2-4 weeks) to assess if continued treatment is needed.
Key side effects at TTH doses: Morning sedation (most common reason for discontinuation), dry mouth, weight gain, constipation
ECG: Recommended in patients >40 years or with cardiac risk factors (QTc prolongation risk)
Mechanism in TTH: Not primarily antidepressant — modulates central pain processing via serotonin and norepinephrine reuptake inhibition, enhances descending inhibitory pathways. Effective at sub-antidepressant doses.
Treatments That Do NOT Work for TTH
SSRIs: Not effective for TTH prevention (same as for migraine). Do not prescribe for headache alone.
Beta-blockers: No evidence for TTH (effective for migraine, not TTH)
OnabotulinumtoxinA (Botox): Multiple RCTs are negative for chronic TTH. Unlike chronic migraine, Botox does not reduce headache days in chronic TTH. Do not use.
CGRP mAbs / gepants: No evidence for TTH prevention. The CGRP pathway does not appear to be a primary driver in TTH pathophysiology.
Anticonvulsants (valproate, gabapentin): No meaningful evidence for TTH
Non-Pharmacologic Treatment
Non-pharmacologic interventions are at least as important as medications for chronic TTH, and in many cases more durable.
Intervention
Evidence
Details
EMG biofeedback
Level A. Cochrane review: moderate effect size. Comparable to amitriptyline in some trials.
Surface EMG from frontalis or trapezius muscles. Teaches voluntary muscle relaxation. 8-12 sessions. Effects are durable after treatment ends.
Cognitive behavioral therapy (CBT)
Level A. Effective for chronic TTH; synergistic with medication.
Targets stress response, pain catastrophizing, and maladaptive coping. 6-8 sessions with a trained therapist. Holroyd et al. (2001): CBT + amitriptyline superior to either alone.
Relaxation training
Level A (progressive muscle relaxation, autogenic training)
Can be self-directed after instruction. Regular practice (daily 15-20 minutes) reduces headache frequency by 30-50%.
Physical therapy
Level B. Multiple positive trials for chronic TTH.
Targets pericranial myofascial dysfunction, postural correction, cervical spine mobility, ergonomic optimization. Manual therapy (cervical manipulation/mobilization) shows benefit in some RCTs.
Acupuncture
Level B. Cochrane (Linde 2016): acupuncture reduces TTH frequency vs no treatment. Small advantage over sham.
10-12 sessions. Reasonable option for patients who prefer non-drug approaches. Similar sham vs true acupuncture debate as in migraine.
Trigger point therapy
Limited but positive small studies
Manual pressure, dry needling, or local anesthetic injection to pericranial myofascial trigger points. Best combined with stretching and physical therapy.
Holroyd et al. (2001): Landmark RCT showing that amitriptyline + stress management/CBT was more effective than either treatment alone for chronic TTH (58% response vs 38% amitriptyline alone vs 35% CBT alone)
Recommended approach for chronic TTH:
Start amitriptyline (10 mg, titrate to 25-50 mg)
Refer for physical therapy (posture, trigger points, cervical spine)
Add behavioral therapy (CBT, biofeedback, or relaxation training)
This combined approach targets both peripheral (myofascial, postural) and central (sensitization, descending inhibition) mechanisms
Special Situations
Chronic TTH vs Chronic Migraine
Many patients with chronic daily headache have features of both chronic TTH and chronic migraine — the ICHD-3 permits dual diagnosis
If any of the chronic headache days have migrainous features (nausea, both photo and phonophobia, pulsating quality, activity worsening), those days count as migraine, and the patient may meet criteria for chronic migraine
Treatment implications: If chronic migraine criteria are met (≥8 migraine days within the ≥15 headache days), the patient is eligible for Botox, CGRP therapies, and other migraine-specific preventives — which are ineffective for pure TTH
Coexisting Migraine and TTH
Very common. Treat the migraine component with migraine-specific therapies (triptans for acute, migraine preventives if frequent)
Treat the TTH component with simple analgesics and non-pharmacologic approaches
Amitriptyline is uniquely useful here because it prevents both migraine and TTH
New Daily Persistent Headache (NDPH)
Distinct entity (ICHD-3 4.10): Daily headache from onset, with clear-cut and specifically recalled onset date
Often has TTH-like features (bilateral, pressing, non-pulsating) but may also have migrainous features
Treatment is empiric: try amitriptyline, then other preventives. Prognosis is variable — some resolve within 2 years, others persist indefinitely.
References
Bendtsen L, et al. EFNS guideline on the treatment of tension-type headache. Eur J Neurol. 2010;17(11):1318-1325.
Holroyd KA, et al. Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination: a randomized controlled trial. JAMA. 2001;285(17):2208-2215.
Bendtsen L, Jensen R. Mirtazapine is effective in the prophylactic treatment of chronic tension-type headache. Neurology. 2004;62(10):1706-1711.
Linde K, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. 2016;(4):CD007587.
Jackson JL, et al. Tricyclic and tetracyclic antidepressants for the prevention of frequent episodic or chronic tension-type headache in adults: a systematic review and meta-analysis. J Gen Intern Med. 2017;32(12):1351-1358.
Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
