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Cited by 457Migraine and Headache StudiesTemporomandibular Joint DisordersMusculoskeletal pain and rehabilitation

Management of Chronic Tension-Type Headache With Tricyclic Antidepressant Medication, Stress Management Therapy, and Their Combination: A Randomized Controlled Trial

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Holroyd, Kenneth A., O'Donnell, Francis J., Stensland, Michael, Lipchik, Gay L., Cordingley, Gary E., Carlson, Bruce W.·2001·JAMA
DOI 10.1001/jama.285.17.2208PMC PMC2128735
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Abstract

Context: Chronic tension-type headaches are characterized by near-daily headaches and often are difficult to manage in primary practice. Behavioral and pharmacological therapies each appear modestly effective, but data are lacking on their separate and combined effects. Objective: To evaluate the clinical efficacy of behavioral and pharmacological therapies, singly and combined, for chronic tension-type headaches. Design and Setting: Randomized placebo-controlled trial conducted from August 1995 to January 1998 at 2 outpatient sites in Ohio. Participants: Two hundred three adults (mean age, 37 years; 76% women) with diagnosis of chronic tension-type headaches (mean, 26 headache d/mo). Interventions: Participants were randomly assigned to receive tricyclic antidepressant (amitriptyline hydrochloride, up to 100 mg/d, or nortriptyline hydrochloride, up to 75 mg/d) medication (n = 53), placebo (n = 48), stress management (eg, relaxation, cognitive coping) therapy (3 sessions and 2 telephone contacts) plus placebo (n = 49), or stress management therapy plus antidepressant medication (n = 53). Main Outcome Measures: Monthly headache index scores calculated as the mean of pain ratings (0-10 scale) recorded by participants in a daily diary 4 times per day; number of days per month with at least moderate pain (pain rating ≥5), analgesic medication use, and Headache Disability Inventory scores, compared by intervention group. Results: Tricyclic antidepressant medication and stress management therapy each produced larger reductions in headache activity, analgesic medication use, and headache-related disability than placebo, but antidepressant medication yielded more rapid improvements in headache activity. Combined therapy was more likely to produce clinically significant (≥50%) reductions in headache index scores (64% of participants) than antidepressant medication (38% of participants; P = .006), stress management therapy (35%; P = .003), or placebo (29%; P = .001). On other measures the combined therapy and its 2 component therapies produced similar outcomes. Conclusions: Our results indicate that antidepressant medication and stress management therapy are each modestly effective in treating chronic tension-type headaches. Combined therapy may improve outcome relative to monotherapy.

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  • For patients with symptoms that are refractory to pharmacological therapies, and those who have comorbid conditions or psychological symptoms, a combination of a gut-brain neuromodulator and psychological therapy may be more efficacious than monotherapy with either.

    “For patients with symptoms that are refractory to these pharmacological therapies, and those who have comorbid conditions or psychological symptoms, a combination of a gutbrain neuromodulator and psychological therapy may be more efficacious than monotherapy with either, drawing parallels with evidence from the depression and chronic headache literature.288 289”

    From British Society of Gastroenterology guidelines on the management of irritable bowel syndrome (2021) · cites this paper as [289]

    The Abstract and COMMENT report that, in adults with chronic tension-type headache, tricyclic medication plus stress-management therapy produced clinically significant headache reductions more often than either treatment alone, though other outcomes were similar. The Participants and COMMENT sections do not establish this advantage for patients refractory to medication or those with comorbid conditions or psychological symptoms; the trial excluded several comorbid conditions. No page numbers are provided in our copy. (LLM, conf=0.88)

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Research works printed but not linked: 12

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  2. [2]2. Schoenen J, Wang W. Tension-type headache. In: Goadsby PJ, Silberstein SD, eds. Headache. Boston, Mass: Butterworth-Heinemann; 1997:177-200.
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  6. [16]16. Holroyd KA, Martin PR. Psychological treat- ments for tension-type headache. In: Olesen J, Tfelt- Hansen P, Welch KMA, eds. The Headaches. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000: 643-649.
  7. [18]18. Bogaards MC, ter Kuile MM. Treatment of re- current tension headache: a meta-analytic review. Clin J Pain. 1994;10:174-190.
  8. [26]26. Silberstein SD, Lipton RB, Goadsby PJ. Head- ache in Clinical Practice. Oxford, England: Isis Medi- cal Media Ltd; 1998.
  9. [33]33. Bernstein DA, Borkovec TD. Progressive Relax- ation Training: A Manual for the Helping Profes- sions. Champaign, Ill: Research Press; 1973.
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Authors
Holroyd, K. A., O'Donnell, F. J., Stensland, M., Lipchik, G. L., Cordingley, G. E., & Carlson, B. W.
Affiliations
  • Ohio University (US)
  • Saint Vincent Health System (US)
Corresponding author
Holroyd, Kenneth A.
ORCID
Carlson, Bruce W.
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2001-05-02
Volume
285
Issue
17
Pages
2208
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.285.17.2208
PMC
PMC2128735
OpenAlex
W2002142158
Cited by
457
References
53
Citations by year
2026: 8 · 2025: 10 · 2024: 9 · 2023: 10 · 2022: 10 · 2021: 12 · 2020: 15 · 2019: 12 · 2018: 10 · 2017: 10 · 2016: 11 · 2015: 17 · 2014: 20 · 2013: 18 · 2012: 20
FWCI
16.53
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health
  • National Institute of Neurological Disorders and Stroke (NS32374, R01NS032374)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Migraine and Headache Studies
  • Health Sciences › Health Professions › Complementary and Manual Therapy › Temporomandibular Joint Disorders
  • Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
Keywords
chronic tension-type headache, tricyclic antidepressants, amitriptyline, nortriptyline, relaxation training, cognitive coping, headache-related disability, analgesic use, headache frequency
MeSH terms
Adult, Amitriptyline, Antidepressive Agents, Tricyclic, Behavior Therapy, Chronic Disease, Combined Modality Therapy, Female, Humans, Male, Nortriptyline, Relaxation Therapy, Stress, Psychological, Cognitive Behavioral Therapy, Tension-Type Headache

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