Diagnosis and Management of Chronic Daily Headache

Ivan Garza, M.D.; Todd J. Schwedt, M.D.


Semin Neurol. 2010;30(2):154-166. 

In This Article

Chronic Tension-type Headache

Chronic tension-type headache is considerably less prevalent than episodic tension-type headache.[44] A telephone survey obtained from 1993 to 1994 in Baltimore, Maryland, found an overall prevalence of 38.3% for episodic tension-type headache and a 1-year period prevalence of chronic tension-type headache of 2.2%.[44] Chronic tension-type headache increases in prevalence until the fourth decade of life and then decreases. Chronic tension-type headache is more prevalent in women compared with men and psychiatric disorders may be risk factors for its development.[44–48]

Although peripheral mechanisms apparently play a role in episodic tension-type headache pathophysiology, central mechanisms may play a larger role in chronic tension-type headache.[49,50] Chronic tension-type headache sufferers had a general hypersensitivity to pain stimuli not seen in controls in a study of nociceptive processing.[51] Central pain inhibition may be dysfunctional in chronic tension-type headache. Research using high-density electroencephalogram (EEG) brain mapping has found the supraspinal response to muscular pain to be abnormal in chronic tension-type headache sufferers.[52] The reduced magnitude during and after induced tonic muscle pain in controls, but not in chronic tension-type headache patients, might be a consequence of impaired inhibition of the nociceptive input in chronic tension-type headache.[52] Deficient diffuse noxious inhibitory control-like mechanisms, such as seen in generalized chronic pain like fibromyalgia, have been found in chronic tension-type headache.[53] Voxel-based morphometry and magnetic resonance imaging (MRI) have identified a significant gray matter decrease in regions involved in pain processing in chronic tension-type headache patients.[54]


Because it largely consists of head pain alone, tension-type headache is frequently called "the featureless headache."[49] Chronic tension-type headache typically evolves from episodic tension-type headache[55] and is usually bilateral, pressure-like in quality, and mildly to moderately intense. "Wearing a tight hat, wearing a tight band around the head, or wearing a heavy burden on the head" are frequent descriptions used by patients.[56] The following are current International Classification of Headache Disorders, 2nd edition (ICHD-2) criteria for chronic tension-type headache.[55]

  1. Headache occurring on ≥15 days per month on average for >3 months (≥180 days per year) and fulfilling criteria 2–4

  2. Headache lasts hours or may be continuous

  3. Headache has at least two of the following characteristics:

    1. Bilateral location

    2. Pressing/tightening (nonpulsating) quality

    3. Mild or moderate intensity

    4. Not aggravated by routine physical activity such as walking or climbing stairs

  4. Both of the following:

    1. No more than one of photophobia, phonophobia, or mild nausea

    2. Neither moderate or severe nausea nor vomiting

  5. Not attributed to another disorder

Of note, the presence of migraine attacks superimposed on a background daily "tension-type" headache could suggest that chronic migraine may be the right diagnosis rather than chronic tension-type headache.[57]


Pharmacologic prophylaxis is the mainstay of treatment. Similar to chronic migraine, effective therapy is continued for at least 3 to 6 months prior to attempting discontinuation.[58] Table 3 summarizes prophylactic medications studied specifically in chronic tension-type headache.

Pharmacologic ProphylaxisAmitriptyline Amitriptyline is the drug of choice, typically at doses ranging from 25 mg to 100 mg per day.[50] This is the only antidepressant used in chronic tension-type headache that has demonstrated statistically significant benefit in several trials.[58] Amitriptyline has an estimated therapeutic gain of ~30% based on published trials.[59,60]

Nortriptyline Nortriptyline has a more favorable side effect profile than amitriptyline.[61] In a randomized placebo-controlled trial, patients with chronic tension-type headache who did not tolerate amitriptyline were switched to nortriptyline at doses of up to 75 mg/day.[62] Both antidepressants produced larger reductions in headache, analgesic medication use, and headache-related disability than placebo.[62]

Protriptyline Twenty-five adult female chronic tension-type headache sufferers were studied using protriptyline 20 mg every morning. Eighty-six percent had fewer headaches per month, and 73% had a ≥50% reduction in headache attacks per month.[63] In contrast to the weight gain associated with other tricyclic antidepressants, patients lost slightly over three pounds during the study.[63] No placebo group was used.

Mirtazapine Bendsten studied mirtazapine in a randomized, double-blind, placebo-controlled, crossover trial. Mirtazapine 15 to 30 mg/day or placebo was given for 8 weeks separated by a 2-week washout period.[60] Mirtazapine reduced the area-under-the-headache curve by 34% more than placebo. The drug also reduced headache frequency, duration, and intensity significantly more than placebo. The efficacy of mirtazapine was similar to that of amitriptyline (a therapeutic gain of ~30%).[59,60]

Topiramate In an open study, topiramate (daily dose 25 to 100 mg/day) resulted in a 50% reduction in headache frequency in 73% of 46 chronic tension-type headache patients at weeks 13 to 24.[64] Average headache intensity decreased from 6.13 to 2.07 on the visual analogue scale.[64] Randomized controlled trials are needed to define topiramate's role in the management of chronic tension-type headache.

Sodium Valproate Sodium valproate (500 mg twice per day) was associated with greater reductions in pain frequency than placebo in 41 chronic tension-type headache subjects in a prospective, double-blind, randomized, placebo-controlled trial.[65] The Visual Analog Scale pain rating did not decrease in the active group.

Tizanidine Tizanidine (6 to 18 mg/day in divided doses) was found to be superior to placebo in a randomized, double-blind, crossover study in women with chronic tension-type headache.[66] A separate randomized, double-blind, parallel-group study, however, failed to demonstrate superiority to placebo.[67] To date, one cannot draw firm conclusions for the potential role of tizanidine in chronic tension-type headache.[58]

Others Citalopram and paroxetine have not proven beneficial in chronic tension-type headache prophylaxis.[59,68,69] Further research is needed to determine the potential efficacy of venlafaxine[70] and buspirone.[71] There is no evidence for a beneficial effect of botulinum toxin in chronic tension-type headache.[72]

Complementary/Alernative Treatment In chronic tension-type headache sufferers with coexistent depression, simultaneous treatment for both disorders has shown benefit.[73] Combination treatment is superior to pharmacotherapy or behavioral therapy alone.[58] Combination treatment with behavioral stress management was more likely to achieve clinically significant (≥50%) reductions in headache index scores (64% of participants) than antidepressant medication (38% of participants), stress management therapy (35%), or placebo (29%) in a randomized placebo-controlled trial of 203 chronic tension-type headache subjects.[62]

The potential role of acupuncture in chronic tension-type headache is yet to be defined. In one study, relaxation training induced the best benefit compared with acupuncture and physical training.[74] The potential role of hypnosis[75] and structured massage[76] remain to be determined. Other noninvasive physical treatments with some evidence in chronic tension-type headache prophylaxis include spinal manipulation, cranial electrotherapy, transcutaneous electrical nerve stimulation (TENS)/electrical neurotransmitter modulation combination, and automassage/TENS/stretching combination.[77]

Acute Pharmacologic Therapy Simple analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) remain as the pillar of abortive treatment in tension-type headache.[50] Acetaminophen/isometheptene/dichloralphenazone frequently helps more severe episodes not responding to NSAIDs.


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