From the Guidelines
Amitriptyline is the most effective antidepressant for treating chronic headaches, particularly tension-type headaches and migraines, due to its ability to increase serotonin and norepinephrine levels in the brain and its muscle relaxant properties. The recommended dose of amitriptyline is 30-150 mg/d, as stated in the study by 1. This medication is often started at a low dose of 10-25 mg taken at bedtime and can be gradually increased to 50-100 mg if needed and tolerated. The medication often takes 2-4 weeks to show effectiveness for headache prevention. Other tricyclics like nortriptyline may be better tolerated in some patients.
Some key points to consider when prescribing amitriptyline for chronic headaches include:
- Common side effects include drowsiness, dry mouth, constipation, and weight gain, which is why they're typically taken at night
- For patients who cannot tolerate tricyclics, SNRIs like duloxetine (30-60 mg daily) or venlafaxine (75-150 mg daily) may be alternatives, though they have somewhat less evidence for headache prevention, as mentioned in the study by 1
- It's essential to continue regular headache prevention medication for at least 3-6 months before considering discontinuation, and any discontinuation should be done gradually to avoid withdrawal symptoms, as suggested by 1
- Patient education and involvement in their management plan are crucial, as emphasized by 1, to help them establish realistic expectations and track their progress.
Overall, amitriptyline is a well-established treatment for chronic headaches, and its effectiveness has been consistently demonstrated in various studies, including those by 1, 1, and 1.
From the Research
Antidepressants for Chronic Headaches
- Antidepressants are often used to prevent chronic headaches, and their effectiveness has been studied in various trials 2, 3, 4, 5, 6.
- A meta-analysis of 38 trials found that patients receiving antidepressants were twice as likely to report headache improvement, with an average amount of improvement considered large 2.
- The most commonly used antidepressants for chronic headaches are tricyclic antidepressants, such as amitriptyline, which has been shown to be effective in preventing migraines and chronic tension-type headaches 2, 3, 4, 5.
Types of Antidepressants
- Tricyclic antidepressants, such as amitriptyline, have been found to be effective in preventing chronic headaches, including migraines and tension-type headaches 2, 3, 4, 5.
- Selective serotonin reuptake inhibitors (SSRIs) have been found to be less effective in preventing tension-type headaches, with no difference in headache frequency compared to placebo or amitriptyline 6.
- Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine, have shown preliminary efficacy in preventing migraines and tension-type headaches, but more research is needed to confirm their effectiveness 4, 6.
Comparison of Antidepressants
- A comparison of SSRIs and tricyclic antidepressants found that tricyclic antidepressants were more effective in reducing headache frequency and intake of analgesic medications, but were associated with more adverse events 6.
- A meta-analysis found no differences in outcomes among the three classes of antidepressants studied (tricyclic antidepressants, serotonin antagonists, and selective serotonin reuptake inhibitors) 2.