What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?

In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...

Because TCAs with both 5-HT and NE effects in low doses were a mainstay of treatment by neurologists in the past for migraines, I would favor dual-action agents such as Cymbalta or Pristiq for this combination of conditions. These are cleaner than the TCAs and would offer full antidepressant respons...

It is important to clarify the pattern, frequency, and severity of the patient's migraine headaches. A second consideration is determining which medications the patient uses routinely for migraine prophylaxis and which are used as needed during acute attacks. Patients with comorbid depression and ch...

Nortriptyline

For chronic headaches with MDD, SNRIs and tricyclic antidepressants should both help.

Choice will depend upon a good evaluation and what medications have been tried, in what dosages, why they were stopped, and what side effects the patient had.

Comorbidities, current list of medications, and potenti...

Migraines can be both physiological and psychological. Before starting medication, a good screening for underlying psychological schemas that trigger the migraines should be considered. If underlying trauma and/or stressors have recurring themes, then choose the best therapy approach to address thes...