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First-Line Chronic Daily Headache (CDH) Prevention Medications
Posted Jan 1999

  1. Amitriptyline: (Elavil)
    Effective and inexpensive. Helpful for migraines and daily headache. Sedation, dizziness, dry mouth, weight gain, and constipation are common. Important to begin with only 10 mg. as many patients cannot tolerate more than 10 mg.

  2. Fluoxetine: (Prozac)
    Fewer side effects than amitriptyline, but not as effective. Nausea, anxiety, sexual dysfunction, insomnia are common. Weight gain may occur but is infrequent. Helpful for migraine in some patients. Begin with only 10 mg., as some patients cannot tolerate more than 10 mg. per day. Expensive. Sertraline (Zoloft) is very similar, as is Paroxetine (Paxil). All of these SSRIs have been useful for preventing chronic daily headache and even for migraine. Considering tolerability, these are often the best choice for chronic daily headache.

  3. Protriptyline: (Vivactil)
    Effective and nonsedating. Weight gain does not occur. Dry mouth, constipation, dizziness are common. Used in the morning, as insomnia is a common side effect. May be used in the morning with a sedating tricyclic at night.

  4. Nortriptyline: (Pamelor, Aventyl)
    Better tolerated than amitriptyline, but less effective. Side effects are similar to amitriptyline, but less severe. Useful in children, adolescents, and the elderly. Occasionally helpful in migraine.

  5. Doxepin: (Sinequan)
    Very similar to amitriptyline; more effective than nortriptyline, but with increased side effects. Begin with very low doses (10 mg. each night), as many patients cannot tolerate more than this amount.

  6. NSAIDs:
    Not as effective as antidepressants for chronic daily headache, but without the cognitive side effects. GI side effects are common, however. Hepatic and renal blood tests need to be monitored. NSAIDs are used more frequently in younger patients. Ibuprofen is available over the counter. Naproxen (Naprosyn, Anaprox) is more effective than ibuprofen. Flurbiprofen (Ansaid), diclofenac sodium (Voltaren), and ketoprofen (Orudis) are also utilized. As always, attempt to use the minimum effective dose. The COX-2 inhibitors (Celebrex, etc.) may be useful without the GI side effects.

  7. Valproate: (Depakote)
    Effective for daily headache and migraine; the dose varies widely, from 250 to 2,500 mg. per day. GI upset and fatigue are common. Weight gain and alopecia may occur. Need to wait at least 4 weeks before abandoning valproate. One of the most widely used and effective preventives for migraine and CDH.