Can trazodone be used to treat persistent headaches?

Trazodone is Not Recommended for Persistent Headaches

Trazodone is not recommended for the treatment of persistent headaches as there is no evidence supporting its efficacy for this indication. 1

Evidence Against Trazodone for Headaches

• Guidelines explicitly state there is no evidence from controlled trials supporting the use of trazodone for migraine prevention 1
• Current clinical practice guidelines (2023-2024) do not include trazodone in any recommendations for headache management 1
• Even in pediatric migraine studies, trazodone showed no efficacy in reducing the frequency of headache attacks 2

Recommended First-Line Treatments for Persistent Headaches

For Migraine Prevention:

• Strong recommendations for:
  • Candesartan or telmisartan 1
  • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1
• Suggested options (weak recommendations):
  • Topiramate 1
  • Propranolol 1
  • Valproate 1
  • Memantine 1
  • Oral magnesium 1
  • Lisinopril 1

For Tension-Type Headache Prevention:

• Amitriptyline is suggested for chronic tension-type headache prevention 1

For Acute Headache Treatment:

• NSAIDs (ibuprofen, naproxen, aspirin) are recommended for mild to moderate headaches 3
• Triptans (sumatriptan, rizatriptan, zolmitriptan) are recommended for moderate to severe migraine 3
• Combination therapy with aspirin-acetaminophen-caffeine is strongly recommended 1, 3

Why Trazodone Might Be Considered (But Should Be Avoided)

• Trazodone is primarily approved for depression treatment but is commonly used off-label for insomnia 4, 5
• Some patients with headaches also experience sleep disturbances, which might lead to consideration of trazodone 5
• However, there are better evidence-based options for both headache treatment and sleep management 1

Clinical Decision Algorithm for Persistent Headaches

1. Determine headache type (migraine, tension-type, cluster)
2. For migraine prevention:
   • First-line: Candesartan/telmisartan or CGRP monoclonal antibodies 1
   • Second-line: Topiramate, propranolol, valproate, memantine 1
3. For tension-type headache prevention:
   • First-line: Amitriptyline 1
4. For acute treatment:
   • Mild-moderate: NSAIDs or acetaminophen 3
   • Moderate-severe: Triptans or combination therapy 3

Important Caveats

• Medication overuse headache can result from frequent use of acute medications (more than twice weekly) 3
• Avoid opioids for migraine treatment as they can lead to dependency and rebound headaches 3
• When selecting preventive therapy, consider comorbidities, side effect profiles, and patient preferences 1
• For patients with both headache and insomnia, consider evidence-based treatments for both conditions separately rather than using trazodone 5