May 1, 2001 -- Since headaches affect so many of us, we may just write them off as an unpleasant fact of life. Long-term, persistent tension headaches occur about every other day in 3% of women -- and in about half as many men -- and they interfere with work in almost half of sufferers.
The best shot at knocking out these tenacious headaches, according to a new study, is with a combination of antidepressants and stress-management therapy. This two-sided attack works better than either treatment alone, say researchers.
The study appears in the May 2 issue of TheJournal of the American Medical Association.
Do you have tension headaches or migraines? WebMD has a place to talk about it: Migraines: Open Discussion.
"Lots of people with [recurrent] headaches may have tried treatment that didn't work, so now they're not seeking treatment anymore," says researcher Kenneth A. Holroyd, PhD, a professor of psychology at Ohio University in Athens. "Our study suggests that they shouldn't give up -- this combination improves the quality of life for many."
And the use of antidepressants doesn't indicate that doctors think the headaches are a symptom of the blues.
"Just because headache patients are given antidepressants doesn't mean that they're depressed," Lawrence C. Newman, MD, tells WebMD after reviewing the findings. These medications relieve pain apart from any effect on depression, explains Newman, director of the Headache Institute at St. Luke's-Roosevelt Hospital in New York.
Holroyd's team studied more than 200 adults with tension headaches occurring 26 days a month, on average. About three-quarters of the people studied were women, and about half had not seen a doctor in at least six months, despite their history of persistent headaches.
Subjects were placed in one of four groups: one that got an antidepressant medication; another that got an inactive placebo medication; a third that got stress management therapy and placebo; and a fourth that got stress management and an antidepressant medication. The antidepressants used were from an older group of drugs known as tricyclic antidepressants.
Although antidepressants and stress management were each better than placebo in reducing headaches, the number of painkillers taken, and interference with work, the antidepressants worked faster. With combined therapy, 64% of the study volunteers had less than half the number of headaches, compared with 38% of the people on antidepressants alone, 35% of those on stress management alone, and 29% of those on the inactive placebo.
"If you have tension headaches more than 15 days each month, for at least six months, you should consider being on antidepressants," Newman says -- except for individuals with an enlarged prostate or with glaucoma, in whom this type of medication is not recommended. The most common side effects -- dry mouth and difficulty urinating -- are usually avoided by giving low doses at bedtime.
"If antidepressants alone don't work, combination treatment, including stress management, may help," Newman explains. This is the usual approach taken by specialized headache centers and some family doctors, he says.
Stress management therapy in this study involved teaching relaxation techniques and coping skills to the participants.
"Younger patients tend to respond better to stress management therapy," Jerome Goldstein, MD, director of the San Francisco Headache Clinic and Clinical Research Center, tells WebMD when asked for independent comment.
"We can't make all stress go away, so it's important to learn to manage stress," says Lisa K. Mannix, MD, a neurologist in Cincinnati. "While learning and applying stress management techniques may not be a 'quick fix,' the long-term benefits are worth the investment."
Holroyd has a few practical tips for cutting down on stress that can worsen headache:
- Take breaks from the computer or office work to get up and stretch.
- Don't cradle the phone receiver between your ear and shoulder.
- Avoid slumped or strained positions.
- Keep a diary of headache activity -- this may help identify and eliminate situations that trigger headaches.
"Patients who do not have access to formal stress-reduction programs may consider self-help books on stress reduction or meditation," Morris Maizels, MD, tells WebMD when asked for independent commentary. He was not involved with this study.
"While the last decade has seen major advances in the causes and treatment of migraine, tension-type headaches remain a mystery," says Maizels, a family practitioner with Kaiser Permanente in Woodland Hills, Calif.
Muscle and psychological tension are not always part of tension-type headaches, and tension headaches are often misdiagnosed as migraine, Maizels explains.
"All patients with daily headache should have a medical evaluation, as a small number of these may have an underlying cause," he says.
A common cause is overuse of pain pills and headache remedies, which Maizels refers to as an "undiagnosed epidemic." Physicians are often unaware of the condition, which usually gets better once patients cut down on use of painkillers.