Spannungskopfschmerz — Verspannung & Schmerzen in der Privatpraxis Dr. Ackermann, Herzogenaurach

Tension Headache Treatment with Botulinum Toxin

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Private practice Dr. Ackermann · Herzogenaurach

Tension headache — when botulinum toxin is worth considering, and when it isn’t.

Episodic tension headache is not an indication for botulinum toxin: no approval, insufficient evidence. Per the guideline, amitriptyline, endurance exercise and relaxation techniques come first. For chronic tension headache (≥15 days/month), the evidence is inconsistent — here, after exhausting guideline-consistent therapy and after counseling on this uncertainty, I offer an off-label trial on a case-by-case basis. For mixed pictures with chronic migraine, an approved treatment option is often available.

This page provides an evidence-based explanation — and shows why the differential diagnosis is the actual work.

Headache · Tension Type · Differential Diagnosis First

Tension Headache — and the Question of Botulinum Toxin

Botulinum toxin type A is not approved for tension headache, and the evidence is inconsistent — that belongs at the start of this page, not the end. What follows is still often useful: the precise distinction of what you're actually dealing with.

A note on terminology: Many patients search for “Botox” — a brand name of one single product that has become a colloquial umbrella term. The active substance is botulinum toxin type A, contained in several licensed medicinal products. All of them are prescription-only and are injected exclusively by the physician after a medical examination. This page uses the substance name throughout — it refers to the same treatment commonly known as a Botox treatment.

ApprovalNoneNot approved under German drug law for tension headache — unlike chronic migraine.

EvidenceInconsistentOne meta-analysis positive, another finding no significant benefit over placebo.

Most common findingMixed pictureMany patients presenting with "tension headache" meet the criteria for chronic migraine on careful history-taking.

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Short answer: For pure, infrequent tension headache there is no approval and no sufficient evidence for botulinum toxin — here, amitriptyline, endurance exercise, relaxation techniques and physiotherapy come first, per the guideline. For chronic tension headache (≥15 days/month) and for mixed pictures with chronic migraine, the practice takes a more differentiated view: anyone meeting the criteria for chronic migraine has an approved treatment option. Anyone who doesn't meet them, but suffers on several burdensome days a month, can be treated off-label in individual cases — after separate counseling, without a promised outcome. The most important work on this page is the distinction itself.

Dr. Thomas Ackermann's practice · Clinical approach

Patients come in with a diagnosis of "tension headache" — and on careful history-taking, turn out not infrequently to have chronic migraine, often with a tension component. This distinction isn't academic; it decides the path forward. And where someone truly has pure, burdensome tension headache: even eight days a month are eight lost days, and four can shape everyday life. That's why the classification comes first — approved migraine indication, off-label case-by-case decision, or guideline-consistent first-line therapy — not the treatment protocol.

— Dr. med. Thomas Ackermann · Specialist in Anesthesiology

Classification · Who benefits, who doesn't

Three patterns, three different paths

Headache pattern	Features	Botulinum toxin
Episodic tension headache	<15 days/month, usually <1–14 days; bilateral, pressing, mild to moderate	Not approved, evidence insufficient. Guideline-consistent: painkillers as needed, endurance exercise, relaxation techniques
Chronic tension headache	≥15 days/month over >3 months, without migraine features	Not approved (off-label); evidence inconsistent (see below). Case-by-case decision where there is corresponding suffering, after separate counseling
Chronic migraine with a tension component	≥15 headache days/month, of which ≥8 with migraine features, plus additional pressing tension-type days	Approved as migraine therapy (PREEMPT) — clinically often under-treated because it gets misclassified as "tension headache." See Migraine Treatment
Medication-overuse headache	Painkillers on >10–15 days/month	First, medication withdrawal under medical supervision, then reassess

Criteria per ICHD-3 (International Headache Society) and the DGN/DMKG guideline on tension headache (AWMF 030-077), which names amitriptyline and comparable substances as first-choice drug prophylaxis and recommends non-drug measures (endurance exercise, relaxation techniques, biofeedback, physiotherapy). Botulinum toxin is not part of guideline-consistent first-line therapy for tension headache.

Why I also treat chronic tension headache off-label

For chronic migraine, the evidence is clear and the approval narrowly defined (see Migraine Treatment with Botulinum Toxin). For chronic tension headache, it is not: one meta-analysis (Dhanasekara 2023) found a significant reduction in headache frequency, intensity and pain-medication use, while a systematic review that also covered cervicogenic headache (Roland 2021) found no significant benefit over placebo in most of the included trials. That doesn't mean a treatment is ineffective — it means it isn't robustly proven. Anyone who spends many days a month with pressing headache, has already exhausted guideline-consistent options, and after counseling about this thinner evidence wants to try treatment, I offer that on a case-by-case basis — off-label, measured against a headache diary, without a promised outcome. In the least favorable case, what remains is a smoother forehead.

Evidence · Figures, not a promise

What the research shows — and where it disagrees

Study	Design	Result
Dhanasekara et al. 2023	Meta-analysis, 11 controlled trials, 687 participants	Significant reduction in headache frequency (−2.8 days/month), intensity and acute-medication use vs. placebo — with explicitly limited study quality
Roland et al. 2021	Systematic review, 12 randomized, placebo-controlled trials on tension-type and cervicogenic headache combined (8 on chronic tension headache, 4 on cervicogenic headache)	Majority of trials with no significant difference from placebo; no clear clinical evidence
Wieckiewicz et al. 2017	Systematic review, 11 prospective and retrospective cohort studies	Significant association between botulinum toxin and reduced pain intensity in most included studies

Dhanasekara CS et al. 2023, Cephalalgia 43(3), PMID 36786349, DOI 10.1177/03331024221150231. Roland SB et al. 2021, Scand J Pain 21(4):635–652, PMID 34090319, DOI 10.1515/sjpain-2021-0038. Wieckiewicz M et al. 2017, Toxins 9(11):370, PMID 29140286, DOI 10.3390/toxins9110370. Three independent evaluations of the same body of evidence reach different conclusions — that is the honest state of the science, not a calculation error in one of the papers. Researched via PubMed and individually verified.

Common situations

Does this sound familiar?

"Diagnosed with tension headache for years — nothing really helps"

Amitriptyline, physiotherapy, relaxation techniques exhausted, the headache remains. A renewed, structured history per ICHD-3 is worthwhile — not infrequently, chronic migraine is hiding behind it.

"Pressing headache plus light sensitivity, nausea"

Pure tension headache rarely comes with autonomic accompanying symptoms. Anyone with both likely has a mixed picture — with an approved treatment option.

"I clench my teeth at night, my head aches by day"

Bruxism, tension headache and migraine share biological pathways and frequently occur together. Looking at the chewing muscles is part of a complete work-up — see Teeth Grinding.

Important to know

What this page is not

Not a substitute for guideline therapy. For episodic tension headache, amitriptyline, endurance exercise, relaxation techniques and physiotherapy come first, per the guideline — not botulinum toxin.
Not a promised outcome. The evidence on chronic tension headache is contradictory; anyone choosing an off-label trial does so after counseling on this uncertainty, with a headache diary as the endpoint, not a promise of success.
Not an offer for multimodal pain therapy. This practice is not a pain clinic. Anyone needing opioid-based treatment, multimodal pain therapy, or a social-medicine assessment is better served at a specialized neurological pain center.
No treatment without a prior differential diagnosis. Before any decision comes the distinction: tension headache, migraine, mixed picture, or medication-overuse headache.

Why this practice

The differential diagnosis is the actual work.

As a Specialist in Anesthesiology with an additional qualification in Manual Medicine/Chiropractic, I look at the muscular and the neurological side of headache together: neck and shoulder tension, chewing muscles, but also the structured history per ICHD-3 that separates episodic migraine from chronic tension headache and from mixed pictures. I am a certified member of the DGBT (German Society for Aesthetic Botulinum Toxin Therapy). This classification decides whether an approved migraine therapy, an off-label case-by-case decision, or guideline-consistent first-line therapy is the right path.

How the first consultation unfolds

Structured history per ICHD-3. Frequency, character, accompanying symptoms, triggers, headache diary. Prior diagnoses are re-examined, not simply adopted.
Differential-diagnostic classification. Tension headache vs. migraine vs. mixed picture vs. medication-overuse headache. Where bruxism is suspected: co-assessment of the chewing muscles.
Treatment history. What has already been tried — amitriptyline, physiotherapy, behavioral approaches — and with what result?
Establishing the indication and counseling per Section 630e of the German Civil Code (BGB). Approved migraine indication, off-label case-by-case decision for chronic tension headache, or guideline-consistent first-line therapy — each option is stated openly, with figures from the studies where they exist, and with the sentence "this isn't proven" where they don't.

The next step

Findings first. Then the decision.

Whether this is tension headache, migraine, or a mixed picture, and which path fits you — that belongs in a personal conversation. Private practice in Herzogenaurach, twelve minutes by car from Erlangen, thirty from Nuremberg and Fürth.

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Frequently asked questions

About Tension Headache and Botulinum Toxin

If it isn't approved — why do you sometimes treat it anyway?

Because approval and guideline describe what has been proven effective in large, unambiguous trials — and because inconsistent evidence isn't the same as proof against a treatment working. Where there is corresponding suffering, after exhausting guideline-consistent options, and after counseling about exactly this uncertainty, I offer a time-limited off-label trial — measured against a headache diary, not a promise of success.

How does tension headache differ from migraine day to day?

Tension headache is typically bilateral, pressing or dull, mild to moderate, doesn't worsen with movement, and rarely comes with nausea or sensitivity to light or sound. Migraine is more often one-sided, throbbing, moderate to severe, and worsens with physical activity. When in doubt, a four-week headache diary helps.

What is medication-overuse headache — could that be my case?

Anyone taking painkillers more than 10–15 days a month can develop a headache caused by the painkillers themselves — a common reason for apparently treatment-resistant chronic headache. The first step is then a medically supervised withdrawal from pain medication over several weeks, since a temporary worsening can occur.

Which non-drug approaches are effective?

Recommended per the guideline: regular endurance exercise (at least three times a week, 30 minutes), progressive muscle relaxation per Jacobson, biofeedback and physiotherapy. Where bruxism or TMD is present, a combination of Manual Medicine and targeted treatment of the chewing muscles can make sense — that is a different indication from tension headache itself.

How long does an off-label treatment last, and when is it assessed?

The effect of botulinum toxin fades on its own after three to four months. Assessment is based on the headache diary, usually after one to two treatment cycles. Without relevant improvement, treatment is ended, not continued.

What if the history reveals chronic migraine instead?

Then — at at least 15 headache days a month, of which at least 8 have migraine features, after inadequate response to oral prevention — there is an approved, guideline-consistent treatment option following the PREEMPT protocol. Details on the Migraine Treatment with Botulinum Toxin page.

When should I get a neurological work-up?

With a first-time headache after age 50, sudden thunderclap pain, headache with fever or neck stiffness, neurological deficits, a change in the character of a previous headache pattern, or headache with visual disturbance, nausea or vomiting without an obvious cause, referral to a specialist belongs before any symptomatic treatment.

Does health insurance cover the cost?

For the approved migraine indication, this practice bills according to the German fee schedule for physicians (GOÄ); private health insurers generally reimburse when the indication is met, depending on the tariff. For off-label treatment of tension headache, reimbursement is generally not to be expected. See the overview under Costs.