Headaches: Tension - Treatment

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• Tertiary amines include amitriptyline (Elavil) and imipramine (Tofranil). Amitriptyline is the tricyclic most commonly used for tension-type headache. These drugs tend to cause more drowsiness than secondary amines, which may be helpful for patients with sleep problems.)
• Secondary amines include desipramine (Norpramin) and nortriptyline (Pamelor, Aventyl). Secondary amines may have fewer side effects than tertiary amines, but they are just as toxic in high amounts.

A tricyclic antidepressant is usually started at a lower dose and then slowly increased. A headache diary can help the patient and the doctor assess the effectiveness of the treatment. In general, patients should remain on preventive drug treatment for at least 6 months. After that time, the doctor will slowly reduce the dose while continuing to monitor the frequency of headache attacks.

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Side effects are fairly common with these medications. Drowsiness is the most common, but may vary by specific drug. In addition, side effects may include dry mouth, constipation, blurred vision, sexual dysfunction, weight gain, trouble urinating, heart rhythm problems, and dizziness. Blood pressure may also drop suddenly when sitting up or standing.

Tricyclics can have serious, although rare, side effects, including heart rhythm problems, which can be dangerous for some patients with certain heart diseases. These drugs can be fatal with overdose.

Other Antidepressants. Selective serotonin-reuptake inhibitors (SSRIs) work by increasing levels of serotonin in the brain. SSRIs used for tension-type headache preventive treatment include paroxetine (Paxil) and citalopram (Celexa). Other antidepressants used for tension-type headache are mirtazapine (Remeron) and venlafaxine (Effexor), which target both serotonin and norepinephrine.

Although these antidepressants have fewer side effects than tricyclics, they do not appear to be as effective for preventive treatment of tension-type headaches.

Investigational Drugs

Tizanidine. Tizanidine (Zanaflex) is a muscle relaxant that is being studied as a possible preventive drug for chronic tension-type headaches.

Botulinum Toxin. OnabotulinumtoxinA (Botox) injections are used to relax muscles and reduce skin wrinkles. Botox is also becoming popular as a treatment for chronic daily headaches, which include tension-type headache. Botox injections are now approved for prevention of chronic migraine in adult. However, Botox has not yet been approved as a treatment for tension-type headaches..

Nitric Oxide Synthase Inhibitors. Nitric oxide synthase inhibitors block nitric oxide, which may play a role in increasing nerve activity that leads to headache. Drugs are currently being investigated for tension-type headache.

Review Date: 11/15/2010
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org).