Comparative effects of pharmacological interventions in the prophylactic treatment of tension-type headache: systematic review and network meta-analysis.
Qing-Feng Tao, Can Hua, Jian-Jiao Mou et al.
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In 30 seconds
This systematic review and network meta-analysis compared medications for preventing tension-type headache (TTH), using randomized controlled trials identified through searches to December 12, 2025. Thirty-five trials were included; 33 involved chronic TTH, and 24 contributed data to meta-analysis. In chronic TTH, amitriptyline 100 mg reduced monthly headache days versus placebo at 4 weeks (MD -6.59, 95% CrI -11.22 to -0.64) and 8 weeks (MD -6.14, 95% CrI -10.27 to -0.87). The authors judged the evidence low to very low certainty and noted high risk of bias and heterogeneity.
Key findings
- Amitriptyline 100 mg reduced monthly headache days versus placebo at 4 weeks (MD -6.59, 95% CrI -11.22 to -0.64).
- At 8 weeks, amitriptyline 100 mg reduced monthly headache days versus placebo (MD -6.14, 95% CrI -10.27 to -0.87).
- BTX-A 100 U reduced monthly headache days (MD -3.79, 95% CrI -7.16 to -0.33).
- Amitriptyline 100 mg and BTX-A 500 U had higher adverse event rates than placebo.
Why it matters
Preventive medication choices for TTH remain uncertain. This synthesis suggests that amitriptyline 100 mg and BTX-A 100 U may reduce headache days in chronic TTH, while also identifying a potential adverse-event trade-off for some regimens. The low to very low certainty of evidence means these comparative estimates should be interpreted cautiously rather than as definitive rankings.
What to keep in mind
The authors report low to very low certainty, high risk of bias, and high heterogeneity; only 24 of 35 included trials contributed data to meta-analysis.