Preventative Treatments for Occipital Headaches

Pharmacological Preventatives

The American College of Physicians recommends amitriptyline for prevention of chronic tension-type headache and occipital neuralgia, with dosages ranging from 30 to 150 mg/day 1, 2
Beta-blockers, such as propranolol 80-240 mg/day and timolol 20-30 mg/day, have strong evidence for efficacy in patients with occipital headaches related to migraine 2, 3
Calcium channel blockers have limited evidence for efficacy in occipital headaches, with flunarizine 10 mg/day showing better results than verapamil 3
Serotonergic agents like methysergide can be effective but require drug holidays due to risk of fibrosis 4, 3
NSAIDs may be used for prevention in some cases, though evidence is stronger for their use in acute treatment 4

Greater occipital nerve block with local anesthetics and/or corticosteroids is both diagnostic and therapeutic, providing relief lasting weeks to months 5
Pulsed radiofrequency of upper cervical nerves may be considered for refractory cases, though evidence is insufficient to make a strong recommendation 5

Physical therapy is recommended for management of tension-type, migraine, or cervicogenic headache 5, 6
Aerobic exercise or progressive strength training is suggested for prevention of tension-type and migraine headache 5, 7
Behavioral interventions, such as biofeedback, cognitive behavioral therapy, mindfulness, and progressive muscle relaxation, have insufficient evidence but may be considered 6

Medication overuse can worsen headaches; limit use of acute medications to avoid this complication 8
Preventive treatments may take 2-3 months to show full benefit; adequate trial periods are necessary 3
After a period of stability, consider tapering or discontinuing preventive treatment 3

The American College of Physicians recommends amitriptyline as the only tricyclic antidepressant with consistent evidence supporting its efficacy for headache prevention, with effective dosages ranging from 30-150 mg/day 9
Anticonvulsants such as divalproex sodium and sodium valproate have good evidence for efficacy in migraine prevention and may be useful for occipital headaches 9
Despite being in the same class as amitriptyline, nortriptyline lacks evidence for efficacy in headache prevention 9, 10
For patients with mixed headache types, amitriptyline has been shown to be superior to beta-blockers 9
Common side effects of tricyclic antidepressants include drowsiness, weight gain, and anticholinergic symptoms 9
The American College of Physicians suggests starting with amitriptyline 10-25 mg at bedtime, gradually increasing to 30-150 mg/day as tolerated 9
If ineffective or poorly tolerated, consider beta-blockers or anticonvulsants, such as divalproex sodium 9

The American Academy of Family Physicians (AAFP) and American College of Physicians (ACP) designate both amitriptyline and propranolol as first-line preventive agents for migraine, with the choice between them depending on the patient's specific headache pattern and comorbidities 11, 12
Amitriptyline is superior to propranolol when patients have mixed migraine and tension-type headache, according to the AAFP/ACP-ASIM guidelines 11, 12
Propranolol is superior to amitriptyline for patients with migraine alone (without tension-type features), as noted by the AAFP/ACP-ASIM guidelines 11, 12

The standard dosing range for amitriptyline is 30-150 mg daily, as recommended by the AAFP/ACP-ASIM guidelines 11, 12
The standard dosing range for propranolol is 80-240 mg daily, according to the AAFP/ACP-ASIM guidelines 11, 12

The AAFP recommends starting low and titrating slowly over weeks to months, with clinical benefits may not become apparent for 2-3 months 12
An adequate trial requires reaching therapeutic dosing for at least 2-3 months before declaring treatment failure, as suggested by the AAFP/ACP-ASIM guidelines 12

Amitriptyline may cause weight gain, drowsiness, anticholinergic symptoms (dry mouth, constipation), according to the AAFP/ACP-ASIM guidelines 11, 12
Propranolol may cause fatigue, depression, nausea, dizziness, insomnia, but is generally fairly well tolerated, as noted by the AAFP/ACP-ASIM guidelines 11, 12