Anxiety and depression occur in migraine patients 2 to 3 times more often than in those without headaches. The opposite is also true, those with anxiety and depression are more likely to develop migraines. Certain antidepressants, such as amitriptyline (Elavil), nortriptyline (Pamelor), venlafaxine (Effexor), and duloxetine (Cymbalta) have been shown to help prevent headaches. However, when an antidepressant (or any other drug) is being tested for the prevention of headaches, patients with depression and anxiety are usually excluded. This is done to clearly establish if a drug works to prevent headaches directly, rather than indirectly through relieving anxiety and depression. There have been no studies of drugs to treat people who have both conditions. A report by Dr. Morris Meizels published in the current issue of Headache presents cases of three patients with severe migraines and anxiety who did not respond to the usual preventive medications. They did respond very well when he prescribed clonazepam (Klonopin), which is a tranquilizer in the family of benzodiazepines. Diazepam (Valium) and alprazolam (Xanax) are two other well-known members of that family, but they all have somewhat different clinical properties. Dr. Meizels stresses the fact that these drugs are potentially addictive and habituating and should be used in carefully selected patients and under close supervision.
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