Frequent and troublesome tension-type headache

If you suffer from frequent tension-type headaches — more than twice a week on a regular basis — and especially if you are getting headaches almost every day (chronic tension-type headache), you should consult your doctor.

Your doctor may recommend a preventive treatment for your tension-type headaches. The most effective preventive treatment for tension-type headache is amitriptyline (Endep).

Simple pain relief medicines for headache tend to become less effective the more of them you take.

Even if pain relievers do remain effective, they ideally should not be taken for more than 2 to 3 days a week on regular basis, as overuse of these medicines can lead to medication overuse headache.

Amitriptyline is also used as a treatment for depression. However, this medicine has pain modifying properties which are unrelated to its antidepressant effect. The dose of amitriptyline needed to prevent tension-type headache is usually much lower than doses used for depression.

If you are prescribed amitriptyline to prevent tension-type headaches there are some things you must remember:

  • You may not notice an effect from amitriptyline immediately, as preventive medicines can take several weeks to exert their full effect. Continue to take amitriptyline as your doctor has prescribed during this period, unless you are experiencing intolerable side effects. Whatever the case, do not stop taking your medicine without telling your doctor.
  • Side effects with amitriptyline will be less likely if you start on a low dose and increase this gradually over a few weeks under your doctor’s instruction. Common side effects include dry mouth, dizziness, drowsiness, blurred vision, constipation and weight gain.
  • If amitriptyline proves effective, your doctor will probably suggest you continue treatment for around 6 months, before slowly weaning you off the medicine to see if your headaches reoccur.

Less commonly used preventive treatments for tension-type headaches include the antidepressants clomipramine (Anafranil, Chemmart Clomipramine), nortriptyline (Allegron) and dothiepin (Dothep). Newer antidepressants such as venlafaxine (Effexor) and mirtazapine (APO-Mirtazapine, Avanza) are sometimes used but are not subsidised on the PBS for the treatment of headache and therefore may be expensive. The selective serotonin re-uptake inhibitors (SSRI) antidepressants fluoxetine, sertraline and citalopram do not seem to be effective at all and are not recommended. Note that use of antidepressants for headaches may be an off-label use, which means the TGA has not approved the use for this treatment. 

As is the case with amitriptyline, the pain-relieving properties of these medicines are not directly related to their antidepressant effects.

  • British Association for the Study of Headache. Guidelines for all health professionals in the diagnosis and management of migraine, tension-type-type headache, cluster headache and medication overuse headache. Hull: BASH, 2010. (accessed 13 December 2011)
  • Neurology Writing Group. Therapeutic Guidelines: Neurology, Version 4 Updated November 2011 [eTG complete CD-ROM]. Melbourne: Therapeutic Guidelines Ltd, 2011.
  • Loder E, Rizzoli P. Tension-type headache. BMJ 2008;336:88–92
  • Bendtsen L, Evers S, Linde M, et al. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. European Journal of Neurology 2010;17:1318-25.