Combination headache: practical experience with a combination of a beta-blocker and an antidepressive

In the prophylaxis of migraine beta-blockers are commonly used. In the therapy of tension headache (TH) the use of tricyclic antidepressives is widespread. Therefore, from a rational point of view, one should combine an antidepressive and a beta-blocker in the treatment of combination headache (CH), in which patients have both migraine and TH. In an open uncontrolled study, 61 patients with CH received a combination of an antidepressive (amitriptyline) or amitriptyline-N-oxide and a beta-blocker (propranolol or metoprolol) for at least 3 months. The 61 patients kept a diary in which they recorded frequency and duration of migraine attacks and tension headaches. The median migraine attack frequency decreased in the 3 months from four to two and the mean attack duration per month from 2 to 0.7 days. TH frequency was reduced from a median of 21 days to 6 days; TH duration fell from a median of 21 days to 2.7 days. At first sight, this treatment appears to be highly effective, at least when judged by the results at the group level. Nevertheless, in an open uncontrolled study like this, one must be aware of many problems, which are discussed in detail.