Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination: a randomized controlled trial. (Abstracts of Current Literature).

Holroyd KA, O'Donnell FJ, Stensland M, et al. (Department of Psychology and College of Osteopathy, Ohio University, Athens; Headache Treatment and Research and OrthoNeuro, Westerville, Ohio), JAMA. 2001;285:2208-2215.

This prospective study sought to evaluate the clinical efficacy of single and combined behavioral and tricyclic antidepressant therapies in the treatment of chronic tension-type headache. The inclusion criteria were (1) participant age range of 18 to 65 years and (2) an International Headache Society diagnosis of chronic tension-type headache at 2 separate examinations. The researchers recruited 203 participants (mean age=37 years, 76% women).

After 1 month of baseline assessment, the participants were randomized into 1 of 4 groups: (1) amitriptyline or nortriptyline medication (AM) (n=53), (2) stress management therapy (SMT) plus placebo (n=49), (3) combination therapy (SMT and AM) (n=53), and (4) placebo therapy (n=48). The AM and placebo therapies were double blinded. Medication dose adjustment lasted for 2 months, during which the participants also received 3 hours of SMT.

Patients were examined for 6 months. The primary outcome variable was the headache index, which was the mean of all daily diary pain ratings (0-10 scale) for a 1-month period. Secondary outcome measures were the number of days per month with a headache of at least moderate severity (a score of 5 or greater), analgesic consumption, and headache-related disability as measured by the Headache Disability Inventory.

The groups receiving either AM or SMT showed significant but modest improvements in the outcome variables over the group that received the placebo. Improvement in headache activity occurred more rapidly with AM than SMT. In the AM or SMT groups, only one third of the participants experienced a substantial ([greater than or equal to] 50%) reduction in headache activity. Almost two thirds (64%) of the combined therapy group (AM plus SMT) reported a substantial reduction in headache index scores. No significant advantage for combined treatment over the other therapies was shown in the other outcome variables.

The authors concluded that AM and SMT are each moderately effective in reducing chronic tension-type headaches, analgesic medication use, and headache-related disability. They indicated, however, that combining these interventions may produce a more substantial reduction in headache index scores than either intervention used alone.

Harriet Wittink, PT, PhD
New England Medical Center
Pain Management Program
Boston, Mass