Most headache studies have focused on migraine headache, and tension-type headache has received less attention. This systematic review focuses on the use of tricyclic (TCA) and tetracyclic antidepressants for the prevention of frequent episodic or chronic tension-type headaches in adults.1 Interestingly, while most trials of migraine headache are among patients experiencing episodic migraine headache (<15 headaches/month), tension-type headache trials are mostly among patients with chronic headaches. This review found that TCAs were superior to placebo, reducing the number of headaches by five per month (from 21 to 16 headaches/month), and were also superior to selective serotonin reuptake inhibitors (SSRIs). In contrast, though data were limited to few trials, tetracyclics were found to be no better than placebo in chronic tension-type headache. Comparisons of TCAs to other pharmacologic and non-pharmacologic modalities were limited to a small number of underpowered trials.

In this study, the authors were careful to tease out episodic from chronic headache, whereas many other reviews have lumped all tension-type headaches together. The authors also reported on the patient-reported outcomes of headache frequency per International Headache Society recommendations. These will support more detailed and better shared decision making with patients about the use of TCAs for tension-type headache. Although TCAs do work, their benefit is modest, and the conversation between patients and clinicians should include a frank discussion of whether this headache benefit is worth the potential side effects.

What else do we need? Available evidence suggests that TCAs and acupuncture are effective, widely used prophylactic measures for tension-type headache.1 , 2 SSRIs are reported to be ineffective.3 More highly powered head-to-head studies comparing TCAs and other prophylactic modalities are needed to determine the role of TCAs in preventing tension-type headache. These trials need to examine and report patient-oriented outcomes to promote discussion of tailoring prophylactic options to patients. The decision to initiate prophylaxis of tension-type headache should be based on individual patient conditions, preferences, and adverse effects.4 , 5