Clinical Implications
All headache patients, in particular those with chronic and refractory headache, should be screened for depression. Decisions regarding treatment of comorbid depression should be based on patient preference, disease severity, potential for adverse events, and prior treatment and adherence history. Presently, no established algorithms exist to guide the management of migraine with comorbid depression. Although treating both migraine and depression with a single pharmaceutical agent appears desirable, in practice this approach is often inadequate and can further complicate the clinical picture. Adjusting a single drug to meet the dosing requirements of two separate disorders can be precarious, as the maximum tolerated dose of a tricyclic may prove adequate for migraine but not for depression. Outcomes may be improved and side effects minimized by using different agents efficacious for each condition (eg, combining an SSRI/SNRI for depression with an anticonvulsant for frequent migraine; or combining an SSRI/SNRI for depression with a triptan for less frequent migraine attacks). At present, however, there are few empirical data to guide decisions about therapeutic independence, and some anticonvulsants can exacerbate depression. Treatment of both disorders often requires a sequential, staggered start to maximize response, with close monitoring of potential drug–drug interactions and adverse events, particularly among older adults. Although controversy remains about the actual risk of serotonin syndrome among patients on an antidepressant and a triptan, existing data and differing serotonin (5-HT) receptor bindings do not seem to justify routinely avoiding this combination, so long as the prescribing physician proceeds cautiously and monitors the patient regularly.
Supplementing pharmacotherapy for depression or migraine with CBT for the other comorbidity is an efficacious strategy that avoids concerns about drug interactions. In cases where depression is mild to moderate and migraine is severe, CBT for depression may be sufficient while preventive therapy for migraine is initiated. Positive outcomes with either preventive pharmacologic and/or behavioral migraine therapies can be achieved among migraineurs with depression, so long as acute migraine treatment is optimized. Finally, because depression is the psychiatric disorder most commonly associated with the use of CAM, guiding patients to use these emerging therapies in an efficacious manner is of significant clinical importance.