Neurol Sci (2012) 33 (Suppl 1):S117–S118 DOI 10.1007/s10072-012-1055-4
ANIRCEF SYMPOSIUM: MIGRAINE AND DEPRESSION
Migraine and depression comorbidity: antidepressant options R. Torta • V. Ieraci
Ó Springer-Verlag 2012
Abstract Migraine and mood depression demonstrate a high clinical relation and share, also with pain, neurobiological mechanisms, particularly neuro-transmettitorial and phlogistic ones. The choice of an antidepressant to treat both depression and migraine is determined by its efficacy, safety, and tolerability. Antidepressants share comparable effectiveness for the treatment of depressive disorders, but their efficacy on headache varies widely: Tricyclic antidepressants are more effective than SNRIs and SSRIs, but demonstrate dose-limiting side effects. Keywords
Migraine Mood depression Antidepressants
Introduction Migraine and mood depression demonstrate a high clinical relation [1] and people with migraine are about three times more likely to have a major depressive disorder than nonmigraineurs [2]. Migraine, depression and pain share neurobiological mechanisms, particularly neuro-transmettitorial and phlogistic ones [3, 4]. The choice of a medication for depression and migraine has to consider several factors, such as: (1) the efficacy on both emotional and somatic symptoms, (2) the safety, related to side effects and to interactions on the disease in itself; and (3) the tolerability that includes the pharmacological interactions and the patient’s satisfaction for the cures, strictly related to the R. Torta (&) V. Ieraci Clinical and Oncologic Psychology Unit, University of Turin, Turin, Italy e-mail:
[email protected] V. Ieraci e-mail:
[email protected]
adherence to the therapeutic project. Only the fulfilment of all of these aspects can carry out a complete effectiveness of the pharmacological treatment on the depression– migraine association.
Antidepressants in migraine: prophylaxis and symptomatological treatment Antidepressants are used by 18 % of control patients and by 39 % of all migraine patients, and nearly half of migraine patients have their psychotropics prescribed by a primary care provider [1]. Although antidepressants share comparable efficacy for the treatment of depressive disorders, their efficacy on headache varies widely [2]. Concerning prophylaxis and treatment of migraine, most tricyclic antidepressants (TCAs) potentiate serotonergic and noradrenergic transmission and block activation of trigeminovascular system [5]. Tricyclic antidepressants, mainly amitriptyline, are more effective than placebo in reducing the frequency of migraine attacks and the prophylactic efficacy increases with longer duration of treatment [6–8]. Their superiority to SSRIs [9] is not confirmed by all studies [7]. Unfortunately TCA side effects are a limiting factor in reaching a dosage that could be effective also for the treatment of mood depression: low dosages allow an effective treatment of migraine and pain, but do not block the vicious circle between depression and pain [4]. The SSRI effectiveness on migraine is still under discussion [7–9]: in a Cochrane review, SSRIs are no more efficacious than placebo in patients with migraine, in a 2-month treatment, but long-term studies are lacking [9]. Furthermore, in some migraineurs, acute administration of SSRIs may cause a worsening of migraine [10], probably
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due to a vasodilator response, linked to serotonergic activity on different subtypes of receptors. Some caution and monitoring are warranted for the potential risk of serotonin syndrome with the addition of a triptan to SSRIs/ SNRIs [11]. Also SNRIs have been evaluated in migraine patients with or without comorbid depression. Venlafaxine is superior to placebo for migraine prevention [12] and it shows a comparable effectiveness of amitriptyline on pain parameters, but with a better side effect profile [13]. Duloxetine, another SNRI, was proved to be effective in the treatment of chronic migraine both on clinical and antinociceptive mechanisms [14]. In another study on patients with major depressive disorder and concurrent primary chronic migraine duloxetine showed a fast efficacy and a good tolerability [15]. Conflict of interest The author certifies that there is no actual or potential conflict of interest in relation to this article.
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