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Therapy-Drug Combo Helps Tension Headaches

Antidepressants, stress management ease pain

TUESDAY, May 1 (HealthScout) -- A carefully controlled study finds that a combination of antidepressant drugs and stress-management therapy can help most people who suffer from the crippling pain of chronic tension headaches.

An estimated 2 percent to 3 percent of Americans experience chronic tension headaches, feeling a tightening band of pain around the temples nearly every day.

Researchers at Ohio University in Athens report in the May 2 issue of the Journal of the American Medical Association (JAMA) that nearly two-thirds of patients given the combined treatment had significant relief, much better results than for either medication or psychotherapy alone.

While the combined treatment is used at many centers, "there has not been clear scientific evidence of its effectiveness," says lead study author Kenneth A. Holroyd, professor of clinical and health psychology at Ohio University. The study shows that antidepressant treatment produces some quick results, and the addition of stress management treatment gives "an additional clinically significant reduction in headache pain," Holroyd says.

Experts in the field who have followed the study hail its publication. "It is great that a journal as prestigious as JAMA published the material," says Dr. Seymour Diamond, head of the Diamond Headache Clinic in Chicago, the oldest and largest of its kind. "This adds credibility to what many people have been doing."

"It is wonderful work that shows great promise," says Dr. Stewart Tepper, assistant professor of clinical neurology at Yale University School of Medicine. "One of the great problems in treating chronic tension headaches has been that it is impossible to get response rates above 40 percent. This is the highest response rate that has ever been published."

Tepper says equally important is that the study was controlled, with roughly equal numbers of its 203 participants getting a tricyclic antidepressant alone, stress management therapy alone, combination therapy or a placebo. Yale has been using the combined treatment for years, but it has met with some financial resistance, he says.

"Insurance companies have refused to pay for combination treatment because there was no scientific evidence to support it. Now we've got it," Tepper says.

Tepper says he hopes insurance coverage will be available now.

The combined therapy in the study started with low doses of a tricyclic antidepressant, either amitriptyline or nortriptyline, both available under several brand names. Holroyd says, "It is best to start with a low dose. When you start at a higher dose, the side effects may make the patient uncomfortable so that the treatment is stopped before it works."

The stress management therapy consisted of three face-to-face sessions of relaxation and cognitive coping training, followed by telephone contacts. "We try to make it very accessible," Holroyd says. The therapy can be administered by a psychiatrist, clinical psychologist, a social worker or a specially trained nurse, he says.

The 64 percent success rate of the combined treatment exceeded results with antidepressants alone (38 percent), stress management alone (35 percent), or placebo (29 percent), the researchers report.

At the start of the study, patients experienced tension headaches an average of 26 days a month, Holroyd says. By the end of the study, those getting combination therapy had headaches seven days a month, and a few experienced complete relief, he says.

What To Do

Don't try to self-medicate with pain relievers, either over-the-counter or prescription, Holroyd says. "When you do that on a daily basis you can actually make the headaches worse and harder to treat," probably because the body adapts to the medication, and there is a rebound effect, he says. "You get into a cycle where you have to take more and more."

Information about headaches is available from the National Headache Foundation and the National Institute of Neurological Disorders and Stroke.

Read past HealthScout articles about headaches.

SOURCES: Interviews with Kenneth A. Holroyd, Ph.D., professor of clinical and health psychology, Ohio University, Athens; Stewart Tepper, M.D., assistant professor of clinical neurology, Yale University School of Medicine, New Haven, Conn., and Seymour Diamond, director, Diamond Headache Clinic, Chicago; May 2, 2001 Journal of the American Medical Association
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