Comprehensive management of headache and depression.

Migraine is a highly prevalent episodic headache disorder. When migraine and depression occur together, therapeutic opportunities, as well as limitations, exist. The effective treatment of both migraine and depression begins with making an accurate diagnosis and explaining it to the patient. Behavioral interventions, such as maintaining a regular schedule, getting adequate sleep and exercise, and giving up tobacco, are often useful. In addition, patients with comorbid depression often need supportive psychotherapy. Patients with depression often need antidepressant therapy independent of their migraine attack frequency. Although the mechanism of antidepressants in headache prophylaxis is unknown, it is not the result of treating masked depression. Preventive migraine medication is usually given daily to decrease the frequency of migraine attacks. For the patient with migraine and depression, use an antidepressant. While tricyclic antidepressants may be more effective for migraine, selective serotonin reuptake inhibitors are just as effective for depression and have fewer side effects. For the patient with migraine and epilepsy, or migraine and manic depressive illness, divalproex sodium is the drug of choice. Drug combinations are commonly used for patients with refractory headache disorders. Some combinations, such as antidepressants and beta-blockers, are suggested even in depressed patients.