[A clinical challenge. Pragmatic treatment of migraine and concomitant depression]

The association of migraine and depression has been confirmed in numerous studies and it has been suggested that both diseases influence each other in a bidirectional way. As the conventional antidepressants mostly aggravate a pre-existing depression, treatment of both is a demanding task and should be planned in an interdisciplinary setting with neurologists and psychiatrists experienced in pain management. The pharmacological therapy is mainly based on a modulation of the serotonergic and noradrenergic systems and non-pharmacological treatment is also incorporated. The number of drugs should be kept to a minimum but drugs effective in the treatment of both migraine and depression should be used. Current data favours the use of amitriptylin, although newer studies justify the use of venlafaxin and fluoxetin as second choice drugs.A combination of several antidepressants with acute acting antimigraine drugs can provoke potentially threatening side effects, however, these possible side effects should not lead to suboptimal treatment of patients with depression and concomitant migraine. The current data on the antimigraine effects of common antidepressants are reviewed and advice for the preventive treatment of migraine with concomitant depression is given. Additionally, hazardous interactions and preferable drug combinations are listed.