Prophylactic therapy should be considered in addition to abortive therapy for tension-type headaches (TTH) when patients:

A. Are having more than two headaches weekly: Frequent tension-type headaches significantly impact quality of life and daily functioning. Prophylactic therapy, such as low-dose tricyclic antidepressants, is recommended when headaches occur more than twice per week or cause substantial disability. This approach reduces headache frequency and reliance on abortive medications. B. Are having monthly headaches: Infrequent tension-type headaches are typically managed with abortive therapy alone. Prophylactic treatment is unnecessary for sporadic or mild headaches that do not interfere with daily activities. C. Have exhausted all options: While refractory cases may require additional evaluation, prophylactic therapy is indicated based on headache frequency and severity, not only after all other options fail. Early intervention can prevent chronification. D. Report headaches associated with hormonal changes: Hormone-related headaches, such as menstrual migraine, have a different pathophysiology than tension-type headaches. Prophylactic therapy for TTH is not specifically guided by hormonal triggers.