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Tricyclic antidepressants and headaches: systematic review and meta-analysis.

Jackson JL, Shimeall W, Sessums L, Dezee KJ, Becher D, Diemer M, Berbano E, O'Malley PG - BMJ (2010)

Bottom Line: Tricyclics were more likely to cause adverse effects than placebo (1.53, 95% confidence interval 1.11 to 2.12) and selective serotonin reuptake inhibitors (2.22, 1.52 to 3.32), including dry mouth (P<0.0005 for both), drowsiness (P<0.0005 for both), and weight gain (P<0.001 for both), but did not increase dropout rates (placebo: 1.22, 0.83 to 1.80, selective serotonin reuptake inhibitors: 1.16, 0.81 to 2.97).Tricyclic antidepressants are effective in preventing migraine and tension-type headaches and are more effective than selective serotonin reuptake inhibitors, although with greater adverse effects.The effectiveness of tricyclics seems to increase over time.

View Article: PubMed Central - PubMed

Affiliation: General Medicine Division, Walter Reed Army Medical Center, Washington, DC, USA. Jeffrey.jackson6@va.gov

ABSTRACT

Objective: To evaluate the efficacy and relative adverse effects of tricyclic antidepressants in the treatment of migraine, tension-type, and mixed headaches.

Design: Meta-analysis.

Data sources: Medline, Embase, the Cochrane Trials Registry, and PsycLIT. Studies reviewed Randomised trials of adults receiving tricyclics as only treatment for a minimum of four weeks.

Data extraction: Frequency of headaches (number of headache attacks for migraine and number of days with headache for tension-type headaches), intensity of headache, and headache index.

Results: 37 studies met the inclusion criteria. Tricyclics significantly reduced the number of days with tension-type headache and number of headache attacks from migraine than placebo (average standardised mean difference -1.29, 95% confidence interval -2.18 to -0.39 and -0.70, -0.93 to -0.48) but not compared with selective serotonin reuptake inhibitors (-0.80, -2.63 to 0.02 and -0.20, -0.60 to 0.19). The effect of tricyclics increased with longer duration of treatment (β=-0.11, 95% confidence interval -0.63 to -0.15; P<0.0005). Tricyclics were also more likely to reduce the intensity of headaches by at least 50% than either placebo (tension-type: relative risk 1.41, 95% confidence interval 1.02 to 1.89; migraine: 1.80, 1.24 to 2.62) or selective serotonin reuptake inhibitors (1.73, 1.34 to 2.22 and 1.72, 1.15 to 2.55). Tricyclics were more likely to cause adverse effects than placebo (1.53, 95% confidence interval 1.11 to 2.12) and selective serotonin reuptake inhibitors (2.22, 1.52 to 3.32), including dry mouth (P<0.0005 for both), drowsiness (P<0.0005 for both), and weight gain (P<0.001 for both), but did not increase dropout rates (placebo: 1.22, 0.83 to 1.80, selective serotonin reuptake inhibitors: 1.16, 0.81 to 2.97).

Conclusions: Tricyclic antidepressants are effective in preventing migraine and tension-type headaches and are more effective than selective serotonin reuptake inhibitors, although with greater adverse effects. The effectiveness of tricyclics seems to increase over time.

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Fig 6 Comparison of effectiveness of tricyclic antidepressants with selective serotonin reuptake inhibitors for tension-type and migraine headaches. Trials of mixed and migraine headaches are combined. SSRI=selective serotonin reuptake inhibitor
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fig6: Fig 6 Comparison of effectiveness of tricyclic antidepressants with selective serotonin reuptake inhibitors for tension-type and migraine headaches. Trials of mixed and migraine headaches are combined. SSRI=selective serotonin reuptake inhibitor

Mentions: In a limited number of trials the effectiveness between tricyclics and selective serotonin reuptake inhibitors did not differ for tension-type headaches (average standardised mean difference −0.80, 95% confidence interval −1.63 to 0.02, four studies, I2=89.5%, fig 6) or migraine headaches (−0.22, −0.75 to 0.31, four studies, I2=89.5%). Seven of these trials used amitriptyline and one used desipramine. The doses used were relatively low: the maximum dose of amitriptyline averaged 50 mg, ranging from 25 mg to 75 mg; the dose of desipramine was 150 mg. Despite low doses, tricyclics were more likely than selective serotonin reuptake inhibitors to produce at least 50% improvement in tension-type headaches (relative risk 1.73, 95% confidence interval 1.34 to 2.22, I2=0.0%, three studies, fig 7), and migraine headaches (1.72, 1.15 to 2.55, I2=9.2%, three studies). Tricyclic arms had higher rates of several adverse effects such as drowsiness and dry mouth (table 3), although they did not have higher withdrawal rates for tension-type headaches (1.05, 0.92 to 1.19, two studies, I2=0.0%) or migraine headaches (2.0, 0.90 to 4.47, three studies, I2=0.0%).


Tricyclic antidepressants and headaches: systematic review and meta-analysis.

Jackson JL, Shimeall W, Sessums L, Dezee KJ, Becher D, Diemer M, Berbano E, O'Malley PG - BMJ (2010)

Fig 6 Comparison of effectiveness of tricyclic antidepressants with selective serotonin reuptake inhibitors for tension-type and migraine headaches. Trials of mixed and migraine headaches are combined. SSRI=selective serotonin reuptake inhibitor
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC2958257&req=5

fig6: Fig 6 Comparison of effectiveness of tricyclic antidepressants with selective serotonin reuptake inhibitors for tension-type and migraine headaches. Trials of mixed and migraine headaches are combined. SSRI=selective serotonin reuptake inhibitor
Mentions: In a limited number of trials the effectiveness between tricyclics and selective serotonin reuptake inhibitors did not differ for tension-type headaches (average standardised mean difference −0.80, 95% confidence interval −1.63 to 0.02, four studies, I2=89.5%, fig 6) or migraine headaches (−0.22, −0.75 to 0.31, four studies, I2=89.5%). Seven of these trials used amitriptyline and one used desipramine. The doses used were relatively low: the maximum dose of amitriptyline averaged 50 mg, ranging from 25 mg to 75 mg; the dose of desipramine was 150 mg. Despite low doses, tricyclics were more likely than selective serotonin reuptake inhibitors to produce at least 50% improvement in tension-type headaches (relative risk 1.73, 95% confidence interval 1.34 to 2.22, I2=0.0%, three studies, fig 7), and migraine headaches (1.72, 1.15 to 2.55, I2=9.2%, three studies). Tricyclic arms had higher rates of several adverse effects such as drowsiness and dry mouth (table 3), although they did not have higher withdrawal rates for tension-type headaches (1.05, 0.92 to 1.19, two studies, I2=0.0%) or migraine headaches (2.0, 0.90 to 4.47, three studies, I2=0.0%).

Bottom Line: Tricyclics were more likely to cause adverse effects than placebo (1.53, 95% confidence interval 1.11 to 2.12) and selective serotonin reuptake inhibitors (2.22, 1.52 to 3.32), including dry mouth (P<0.0005 for both), drowsiness (P<0.0005 for both), and weight gain (P<0.001 for both), but did not increase dropout rates (placebo: 1.22, 0.83 to 1.80, selective serotonin reuptake inhibitors: 1.16, 0.81 to 2.97).Tricyclic antidepressants are effective in preventing migraine and tension-type headaches and are more effective than selective serotonin reuptake inhibitors, although with greater adverse effects.The effectiveness of tricyclics seems to increase over time.

View Article: PubMed Central - PubMed

Affiliation: General Medicine Division, Walter Reed Army Medical Center, Washington, DC, USA. Jeffrey.jackson6@va.gov

ABSTRACT

Objective: To evaluate the efficacy and relative adverse effects of tricyclic antidepressants in the treatment of migraine, tension-type, and mixed headaches.

Design: Meta-analysis.

Data sources: Medline, Embase, the Cochrane Trials Registry, and PsycLIT. Studies reviewed Randomised trials of adults receiving tricyclics as only treatment for a minimum of four weeks.

Data extraction: Frequency of headaches (number of headache attacks for migraine and number of days with headache for tension-type headaches), intensity of headache, and headache index.

Results: 37 studies met the inclusion criteria. Tricyclics significantly reduced the number of days with tension-type headache and number of headache attacks from migraine than placebo (average standardised mean difference -1.29, 95% confidence interval -2.18 to -0.39 and -0.70, -0.93 to -0.48) but not compared with selective serotonin reuptake inhibitors (-0.80, -2.63 to 0.02 and -0.20, -0.60 to 0.19). The effect of tricyclics increased with longer duration of treatment (β=-0.11, 95% confidence interval -0.63 to -0.15; P<0.0005). Tricyclics were also more likely to reduce the intensity of headaches by at least 50% than either placebo (tension-type: relative risk 1.41, 95% confidence interval 1.02 to 1.89; migraine: 1.80, 1.24 to 2.62) or selective serotonin reuptake inhibitors (1.73, 1.34 to 2.22 and 1.72, 1.15 to 2.55). Tricyclics were more likely to cause adverse effects than placebo (1.53, 95% confidence interval 1.11 to 2.12) and selective serotonin reuptake inhibitors (2.22, 1.52 to 3.32), including dry mouth (P<0.0005 for both), drowsiness (P<0.0005 for both), and weight gain (P<0.001 for both), but did not increase dropout rates (placebo: 1.22, 0.83 to 1.80, selective serotonin reuptake inhibitors: 1.16, 0.81 to 2.97).

Conclusions: Tricyclic antidepressants are effective in preventing migraine and tension-type headaches and are more effective than selective serotonin reuptake inhibitors, although with greater adverse effects. The effectiveness of tricyclics seems to increase over time.

Show MeSH
Related in: MedlinePlus