A Cochrane review [Abstract] 1 included 8 studies with a total of 412 participants with chronic forms of tension-type headache. A total of 68% of patients were women. The studies evaluated 5 SSRIs (citalopram, sertraline, fluoxetine, paroxetine, fluvoxamine) and one SNRI (venlafaxine). Six studies compared SSRIs to other antidepressants (amitriptyline, desipramine, sulpiride, mianserin). Follow-up ranged between 2 and 4 months.Six studies explored the effect of SSRIs or SNRIs on tension-type headache frequency, the primary endpoint. At 8 weeks of follow-up, there was no difference when compared to placebo (MD -0.96, 95% CI -3.95 to 2.03; 2 studies, n = 127) or amitriptyline (MD 0.76, 95% CI -2.05 to 3.57; 2 studies, n = 152). SSRIs reduce the symptomatic/analgesic medication use for acute headache attacks compared to placebo (MD -1.87, 95% CI -2.09 to -1.65; 2 studies, n = 118). However, amitriptyline appeared to reduce the intake of analgesic more efficiently than SSRIs (MD 4.98, 95% CI 1.12 to 8.84). There were no differences compared to placebo or other antidepressants in headache duration and intensity.SSRIs or SNRI were generally more tolerable than tricyclics. However, the two groups did not differ in terms of number of participants who withdrew due to adverse events or for other reasons (OR 1.04; 95% CI 0.41 to 2.60; and OR 1.55, 95% CI 0.71 to 3.38; 4 studies, n = 257).There were no studies comparing SSRIs or SNRIs with pharmacological treatments other than antidepressants (e.g. botulinum toxin) or non-drug therapies (e.g. psycho-behavioural treatments, manual therapy, acupuncture).
Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment), inconsistency (heterogeneity in treatments and outcomes) and indirectness (short follow-up).
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