In patients with chronic tension-type headache who have completed a trial of first-choice prophylactic therapy without achieving adequate headache reduction, a defined second-line approach applies.
Headache occurring on 15 or more days per month on average for more than 3 months — the defining threshold for chronic tension-type headache — in whom prophylactic pharmacotherapy is indicated.
The patient has received amitriptyline as the first-choice prophylactic agent but has not achieved a good therapeutic effect — specifically, meaningful headache reduction assessed after 4 weeks on the maintenance dose, or has not tolerated the drug. This outcome triggers escalation to the next treatment line.
Second-choice prophylactic agents are available for this situation — the complete regimen, including which agent applies and the monitoring approach, is provided in the full protocol.
DOI: 10.1111/j.1468-1331.2010.03070.x
Headache occurring on ‡15 days per month on average for >3 months (‡180 days per year) and fulfilling criteria B–D.
Prophylactic pharmacotherapy should be considered in patients with chronic TTH, and it can be considered in patients with very frequent episodic TTH.
Mirtazapine and venlafaxine are drugs of second choice.
Mirtazapine, of which the major side effects are drowsiness and weight gain, or venlafaxine, of which the major side effects are vomiting, nausea, dizziness and loss of libido, should be considered if amitriptyline is not effective or not tolerated.
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