Tricyclic antidepressants help ease migraine
Tricyclic antidepressants (TCA) significantly improve headache in adults with migraine compared with placebo, according to a new meta-analysis. Furthermore, TCAs have comparable efficacies with selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs).
Pooled data from seven trials showed that TCAs were significantly more effective than placebo (standardized mean difference [SMD], -0.75; 95 percent CI, -1.05 to -0.46; p<0.00001). Similarly, patients receiving TCAs were more likely to experience ≥50 percent decrease in headache (risk ratio [RR], 1.40; 0.89 to 2.20; p=0.14).
Patients who received the TCA amitriptyline had experienced significantly greater improvements at 6 months (SMD, -0.77; -1.34 to -0.20; p=0.008) than at 1 month (SMD, -0.53; -0.97 to -0.10; p=0.02) indicating increasing efficacy of the medication over time.
Withdrawal due to adverse events was marginally higher in groups that received TCA than placebo (RR, 1.73; 1.00 to 2.99; p=0.05).
Compared to SSRIs, amitriptyline did not have significantly greater impacts on headache burden (SMD, 0.16; -0.32 to 0.63; p=0.52). Similarly, the efficacy of amitriptyline was comparable to that of SNRIs (SMD, -0.13; -0.51 to 0.25; p=0.51).
Based on only one eligible study, there was no significant difference in the response rates for SSRIs and amitriptyline (RR, 1.08; 0.41 to 2.83; p=0.87). However, withdrawal rate because of adverse events was modestly higher for amitriptyline than SSRIs or SNRIs (SMD, 2.85; 0.97 to 8.41; p=0.06).
The meta-analysis involved randomized controlled trials that compared TCAs with placebo or amitriptyline with other antidepressants. Those that were animal trials, employed combination therapies and enrolled patients with secondary headaches were excluded.
Outcomes were migraine frequency and index, treatment response rate, and withdrawal rate. The Cochrane Collaboration tool was used to evaluate methodological quality of the trials.