Propranolol was compared to amitriptyline by Zieglar et al280
and found to be equally effective but that has not been my experience.
Many regard amitriptyline to be the drug of choice in mixed headache
particularly when there is a muscle contraction and depression factor.
Time and experience will indicate whether tricyclic antidepressants are
really as effective as the beta blocking drugs in pure vascular
headaches. "The ideal prophylactic agents for the therapy of migraines
should be early active, possess long‑term efficacy with few side effects
and a convenient dosing schedule, and truly prevent attacks from
occurring rather than merely decreasing their severity."281
The fact is that no such ideal agent has been found.
The
tricyclic antidepressants most commonly used for migraine and tension-type
headache prophylaxis include amitriptyline, nortriptyline, doxepin, and
protryptyline.252 Side effects of tricyclic antidepressants are
common and involve antimuscarinic effects such as dry mouth and sedation.
These drugs also increase appetite and therefore produce weight gain. One
should also be aware of potential cardiac toxicity and orthostatic
hypotension. Tricyclics have also been used cautiously in combination with
MAO inhibitors and with beta-blockers. Selective serotonin reuptake
inhibitors (SSRIs) such as fluoxetine and sertraline are the newest types of
antidepressants that may be effective in some headache patients.
