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Antidepressants for Pain

“Why did my doctor prescribe an antidepressant? I’m not depressed, I have outrageous headaches!” I’m convinced that every headache sufferer asks this question at some point. If doctors don’t explain the reasons or if patients don’t understand them, we feel dismissed or as if our doctors didn’t listen to us.

But there are good reasons behind the drug choice. Some of the same brain chemicals are thought to be shared between the two diseases, so antidepressants can adjust the imbalance of migraine-related chemicals. Also, many antidepressants have pain-soothing properties.

Tricyclic antidepressants, including Elavil (amitriptyline), Tofranil (imipramine) and Pamelor (nortriptyline), have a long track record in treating pain. SSRIs, like Prozac, Effexor and Zoloft, don’t have as much proof supporting their efficacy for pain, but there is some evidence that they help reduce pain as well as treat other symptoms related to migraine, like anxiety.

Mayo Clinic provides an overview of why tricyclics are used for pain, how they work and side effects. The best description of SSRIs for headache that I’ve found is Headache 2005 from the Robbins Headache Clinic. Getting to it requires wading through a PDF, but it’s worthwhile. The SSRI information begins on page 32.

11/18/05: Turns out the chemical imbalance theory of depression is off-kilter. Antidepressants may work on the same areas of the brain affected by headache, but a chemical imbalance isn’t the place.

2 Responses to Antidepressants for Pain

  1. PamC says:

    I’ve had my neuropathic pain specialist say straight up that antidepressants won’t do a damn thing for migraine pain. Sure, there’s a role serotonin plays in migraines. In fact, a shot of serotonin straight to the blood stream is one way to abort a migraine attack. But that’s not what antidepressants do.

    Antidepressants only raise the baseline amount of serotonin in the blood. They have no effect on serotonin spikes or production cessation. It’s like having a rollercoaster at sea-level in Miami and having a rollercoaster a mile high in Denver—there are still going to be the same ups and downs.

    My personal experience with antidepressants is that they did nothing to effect the migraine, nor the prodrome panic attacks or depression that would come with it (both typically last 1-2hs with an attack).

    Role of seratonin in migraine:
    http://www.abpi.org.uk/publications/publication_details/targetMigraine/section4b.asp

  2. Kerrie says:

    Thanks for the information, Pam. There’s a lot of conflicting information on this topic. A search of Google Scholar — http://scholar.google.com/scholar?hl=en&lr=&c2coff=1&q=migraine+ssri+preventive — brings up many journal article abstracts that acknowledge at least some efficacy in antidepressants for migraine. But, as I’m sure you’ve experienced, anyone who’s been a headache patient for very long knows that it’s a matter of trial and error to see what’s going to work from person to person — of if the drug will work at all.

    This paragraph from All in My Head addresses the issues that we both raise:

    “…I heard a variety of doctors clearly make an assertion again about the inadequacy of the currently available preventives. ‘Interestingly, a majority of commonly used [preventives] have little evidence of efficacy. In contrast, almost all options have well document adverse effects, often leading to a discontinuation of preventive therapy,’ read a summary in the program book leading to the presentation of Dr. David W. Dodick, the well-respected director of the Headache Program at the Mayo Clinic branch in Scottsdale, Arizona. This time the assertion was backed up by the citation of many studies, including a major federally sponsored one for 1999 done at Duke University.” (page 285)

    My approach has always been to try a well-researched medication that has at least some evidence supporting its efficacy, but monitor my reactions carefully. If the side effects become too much to bear, or if it simply doesn’t help, work with my doctor to taper off the drug safely. There’s always a chance it will help and if it doesn’t, there’s little or no long-term harm done. (That said, I know I’m more relaxed about taking meds than many people are.)

    Thanks for your comments. I love that a vareity of approaches, experiences and opinions are available here.

    -Kerrie

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