Antidepressant and stress management cut headache pain by half

ATHENS, Ohio – Findings from a clinical trial of chronic tension headaches suggest a combination of an antidepressant and stress management therapy can cut the frequency of headaches by as much as half. The report, published in this week’s Journal of the American Medical Association, could mean relief for millions of Americans plagued by headaches that cause debilitating pain almost daily.

Researchers at Ohio University studied 203 people at two clinics in Ohio who suffer from chronic tension headaches, which affect between 2 percent and 3 percent of the population. Researchers wanted to determine the effectiveness of two types of treatments: a class of antidepressants called tricyclics and brief stress management therapy.

While they found that both treatments helped reduce headache pain, the best results came from a combined approach, said Ken Holroyd, professor of health psychology in the College of Arts and Sciences and leader of this study, which was funded by a $1.3 million grant from the National Institute of Neurological Disorders and Stroke.

“About two-thirds of the participants receiving combined therapy showed at least a 50 percent reduction in headaches, compared to about one-third of people who received either antidepressant medication or self-management therapy alone,” Holroyd said. “These are people who were having pain almost daily, so this significantly improves daily life even if it doesn’t eliminate headaches altogether.”

Tension-type headache patients have bilateral pain or a dull ache in the head and neck; many compare the pressure to a vise. Chronic tension-type headaches are tension headaches that occur at least 15 days per month; among participants in the study, headaches occurred an average of 26 days a month. Although scientists are still figuring out what triggers chronic tension headaches, they know the cause is different than for other types of headaches.

“With chronic tension headaches, the sensitivity of circuits that transmit pain signals to the brain get turned up, much like you might turn up a radio,” Holroyd explained. “So the same pain signal is louder or more painful when it is transmitted to the brain.”

For the study, participants were randomly assigned to one of four treatments: placebo; an antidepressant called amitriptyline; stress management therapy or a combination of amitriptyline and stress management. People taking amitriptyline took the drug in low doses once a day. Stress management therapy involved muscle stretching exercises, relaxation techniques and instruction on identifying and managing stressors that often lead to headaches.

Participants visited one of two headache clinics in the study monthly for three months. Stress-management skills were introduced and the dose of antidepressant medication was adjusted at each visit. Participants in the stress-management group also used manuals and audiotapes to learn and practice those skills at home.

All patients also kept diaries of the frequency and severity of their headaches and their use of pain-relieving medications. Researchers followed the participants for an additional six months to evaluate the effects of the treatment.

Those receiving amitriptyline recorded faster headache relief than those receiving stress-management alone. But the stress-management group showed equal improvement as they learned to identify warning signs that a headache was coming, preventing headaches and reducing the need for medication.

“Generally, there is an effort to taper off the antidepressant after six months to a year,” Holroyd said. “We followed people in this study one year after their participation ended, and people who received the combined treatment were more likely than people who received medication alone to successfully discontinue antidepressant medication.”

The National Headache Foundation reports that 45 million Americans suffer from chronic headaches and spend more than $4 billion each year on over-the-counter pain relievers. For many, the use of such analgesics can actually worsen their pain by causing what Holroyd called “rebound headaches.”

“When you take pain-relieving medication regularly, your body adjusts to that level of medication. Rebound headaches may then occur between medication doses or if you don’t take the medication,” Holroyd said. “For some people, this can be a cyclical problem. They take medication for a headache, get more headaches, take more medication, and so on. This cycle needs to be broken before headaches can be effectively treated.”

Antidepressants such as amitriptyline and other tricyclics do not cause this rebound effect, Holroyd said. Although scientists aren’t sure how such antidepressants reduce pain, they suspect the drugs dampen the sensitivity of circuits that transmit pain signals to the brain.

And while that’s a topic currently under scrutiny in some labs, Holroyd’s 25 years of pain research have focused on ways to reduce pain through a variety of drug and nondrug treatments. His next project – a five-year $2.4 million study of severe migraine headaches – will involve some of the same techniques applied in the chronic tension headache project. He hopes to enroll 250 people in that study, which will get under way this summer at headache clinics in Columbus and Athens.