Med Oral Patol Oral Cir Bucal. 2008 Sep1;13(9):E567-72. Amitriptyline and chronic tension-type headache Med Oral Patol Oral Cir Bucal. 2008 Sep1;13(9):E567-72. Amitriptyline and chronic tension-type headache Publication Types: Review Use of amitriptyline for the treatment of chronic tension-type headache. Review of the literature Eulalia Torrente Castells 1, Eduardo Vázquez Delgado 2, Cosme Gay Escoda 3 (1) Odontóloga. Residente del Máster de Cirugía Bucal e Implantología Bucofacial. Facultad de Odontología de la Universidad de Barcelona (2) Odontólogo. Profesor Asociado de Cirugía Bucal. Profesor responsable de la Unidad de Patología de la ATM y Dolor Bucofacial del Máster de Cirugía Bucal e Implantología Bucofacial. Facultad de Odontología de la Universidad de Barcelona. Especialista de la Unidad de Patología de la ATM y Dolor Bucofacial del Centro Médico Teknon. Barcelona (3) Médico-Estomatólogo y Cirujano Maxilofacial. Catedrático de Patología Quirúrgica Bucal y Maxilofacial. Director del Máster de Cirugía Bucal e Implantología Bucofacial. Facultad de Odontología de la Universidad de Barcelona. Co-director de la Unidad de Patología de la ATM y Dolor Bucofacial del Centro Médico Teknon. Barcelona Correspondence: Prof. Cosme Gay Escoda Centro Médico Teknon C/Vilana nº 12 08022 Barcelona E-mail: [email protected] Torrente-Castells E, Vázquez-Delgado E, Gay-Escoda C. Use of amitrip- Received: 28/09/2007 tyline for the treatment of chronic tension-type headache. Review of the Accepted: 11/07/2008 literature. Med Oral Patol Oral Cir Bucal. 2008 Sep1;13(9):E567-72. © Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698-6946 Indexed in: http://www.medicinaoral.com/medoralfree01/v13i9/medoralv13i9p567.pdf -Index Medicus / MEDLINE / PubMed -EMBASE, Excerpta Medica -SCOPUS -Indice Médico Español -IBECS Abstract Amitriptyline is a tricyclic antidepressant, considered the treatment of choice for different types of chronic pain, including chronic myofascial pain. Its antinociceptive property is independent of its antidepressant effect. Although its analgesic mechanism is not precisely known, it is believed that the serotonin reuptake inhibition in the central nervous system plays a fundamental role in pain control. Although this medication is widely used in the prevention of chronic tension-type headache, few studies have investigated the efficacy of this treatment and the published re- sults are contradictory. The objective of this article was to review the literature published on the use of amitriptyline in the prophylactic treatment of chronic tension-type headache, considering the level of scientific evidence of the different studies using the SORT criteria. From this review, 5 articles of evidence level 1, and another 5 articles of evidence level 2 were selected. Following analysis of the 10 studies, and in function of their scientific quality, a level A recommendation was made in favor of using amitriptyline in the treatment of chronic tension-type headache. Key words: Chronic tension-type headache, amitriptyline. Introduction and TTH constitute the same physiopathologic process, but Tension-type headache (TTH) is described as a dull, non with different clinical manifestations. Migraine possibly pulsatile pain, affecting the entire head, of oppressive and represents a painful condition with an important vascular progressive character, moderate or severe intensity, variable component, while TTH represents a painful condition with duration (up to several days) and lacking the typical fea- a greater myofascial component. The episodic nature of tures of migraine. In 90% of cases the pain is bilateral, the TTH has an average duration of 12 hours, although this can typical location being in the occipital, parietal, temporal vary from 30 minutes up to 72 hours. Chronic tension-type and frontal areas. Occasionally nauseas, photophobia or headache (CTTH) is present for at least 15 days a month phonophobia can appear, with or without associated dys- during a 6-month period (1,2). function of the pericranial muscles. Although the duration Although TTH is the most frequent type of primary heada- and intensity of the pain is variable, this headache is not che (two thirds of the population have suffered an episodic as debilitating as migraine, and sufferers are usually able to TTH and 3% suffer from CTTH), its physiopathology is still continue their daily activities. It is considered that migraine the cause of controversy within the scientific community. Article Number: 1111111477 © Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698-6946 E567 eMail: [email protected] Med Oral Patol Oral Cir Bucal. 2008 Sep1;13(9):E567-72. Amitriptyline and chronic tension-type headache Med Oral Patol Oral Cir Bucal. 2008 Sep1;13(9):E567-72. Amitriptyline and chronic tension-type headache For many years it has been thought that TTH was directly published on the use of AMT in the treatment of CTTH, related with muscular tension. However, more recently it has taking into account the level of scientific evidence and been postulated that although muscular tension is usually following the principals of evidence-based dentistry. present in most cases, it is possible that the origin is more central, due to the hyperexcitability of the trigeminal caudal Material and Method nucleus and of other structures of the central nervous sys- A PubMed-MEDLINE search was carried out of articles tem (CNS) that register, modulate and interpret head pain. published from 1966 to 2006. The MeSH (Medical Subject This abnormality can reduce the pain threshold and make Heading) keywords and headings were used for "CTTH" the patient perceive pericranial musculature contraction as (chronic tension-type headache) to obtain a primary bank painful. Precipitating factors of TTH have been identified as of articles on this pathology. The identified literature was those that interact with the limbic system, and myofascial, then limited to studies in humans and articles written in or vascular structures; the most frequent being emotional English. A similar search was made for AMT (amitrip- stress, anxiety, depression and myofascial pain (3,4). This tyline). Both search types were in turn merged by means pathology type may also be induced, intensified or made of the boolean operator "AND", thus linking the articles chronic by analgesic abuse (5,6). for CTTH and AMT. Two authors analyzed the searched Amitriptyline (AMT) is a tricyclic antidepressant pos- articles to verify their pertinence to the topic under study. sessing an analgesic effect, and is therefore prescribed for The irrelevant articles were discarded. Next, two of the different types of chronic pain, its analgesic property being authors stratified the scientific articles separately according independent of its antidepressive effect (7-10). However, to their level of scientific evidence using the SORT criteria the analgesic mechanism is not precisely known. Probably, (Strength of Recommendation Taxonomy) (tables 1, 2 and serotonin (5-HT) and noradrenaline reuptake inhibition 3). Subsequently, the authors compared their results and, in of the CNS plays a fundamental role in the control of the the event of disagreement, the results were discussed. When pain. CTTH is one of the chronic disorders in which AMT it was not possible to achieve a consensus regarding the level seems to have a positive effect (5,8,11). of scientific evidence of a certain article, a third author was The objective of this article was to review the literature included in the discussion. Subsequently, and in accordance Table 1. Strength of Recommendation Taxonomy (SORT). Strength of Definition Recommendation A Recommendation based on consistent and good-quality, patient-oriented evidence (1) B Recommendation based on inconsistent or limited-quality, patient-oriented evidence (1) Recommendation based on consensus, usual practice, opinion, disease-oriented evidence C (2), or on case series for studies of diagnosis, treatment, prevention or screening (1) Patient-oriented evidence considers the following objectives: reduction of mortality and morbidity, improvement of the symptoms, better quality of life, reduced costs. (2) Disease-oriented evidence comprises intermediate, histopathologic, physiologic and other surrogate or potentially useful results for improving the patient's quality of life (blood sugar, blood pressure, etc.) that may or not reflect the patient's actual improvement. Table 2. Levels of scientific evidence. Abbreviations: SR = systematic review; RCT = randomized clinical trial. Treatment/prevention/ Study quality Diagnosis Prognosis screening Level 1 - good-quality, - SR/meta-analysis of high- - SR/meta-analysis of RCTs with - SR/meta-analysis of good- patient-oriented quality studies consistent findings quality cohort studies evidence - High-quality diagnostic - High quality individual RCT - Prospective cohort study cohort study - All or none studies* with good follow-up Level 2 - limited- - SR/meta-analysis of low- - SR/meta-analysis of low-quality - SR/meta-analysis of lower- quality, patient-oriented quality studies or studies clinical trials or of studies with quality cohort studies or with evidence with inconsistent findings inconsistent findings inconsistent results - Cohort study or low- - Low-quality clinical trial - Retrospective cohort study quality case control study - Cohort study or prospective cohort study - Case control study with poor follow-up - Case-control study - Case series Level 3 - other evidence - Consensus guidelines, extrapolations