In our previous study of on depressive patient were shown appearance of pulstile headache as a most common type of headache mostly located on bilaterally on temporal region and hypothesized that it as an intermediate phenomenon. Depression itself, or may be due to social and cultural variation was identified as a psychiatric suffering that was not recognized as a illness hence thought as iceberg It is well evident that migraine and depression is interchangeable and has bidirectional relationship . Tension band like headache is earliest to be recognized but  it remained poorly recognized possibly may be due more pain tolerance , depression itself has social and cultural variation.   The drug used in the treatment of migraine and depression is little bit more comprehensible to understand. The use of  propranolol  and flunarizine   has depressant properties in long term . Simultaneously the use of flunarizine with SSRIS warn induction of hyperserotonergic syndrome as FDA black box sign. Author has discrete opinion on use of flunarizine in treatment of headache in depression The area of interest with contradictory reports on use of flunarizine...We try to find out role of flunarizine in preventing appearance of depression and transformation of tension band headache, throbbing headache into migraine and finally into depression.

Flunrizine is effective in treatment as well as prophylactic in management of migraine. It is equally effective as pizotifen and long term use as cinarizine in vertigo. Some of the interesting findings  related to its use are its effectively in induction of neo- vascularisation in cerebrovascular as  well as peripheral vascular disease  and improvement in cognitive function  , but it never been compared to methylsergide . [1] The use of flunarizine  is not free from side effect as other drugs . Since it is a  calcium channel inhibitor and anti dopaminergic effect , it appears with side of  anitneuroleptic drugs frequently with movement disorder ,  depression and drowsiness .[2 -3]

Clinical resemblance of chronic pain may variable etiologies . In case of traumatic brain injury will have highest onset of pain syndrome i.e. chronic headache [5]. Migraine and depression study has strong advocacy on bidirectional relationship of migraine, migraine predicting pre onset depression and depression predicting pre onset migraine. Chronic pain may have highest association with depression [6]. The explanation for their bidirectional relationship have common shared pathway. [7, 8] same relationship were found with panic disorder (9<. Other psychiatry condition may also found with migraine and chronic headache Panic disorder may be one of them [12] Others are various anxiety disorder such OCD and anxiety (10).  Supressed anger and anger trait may also be seen in depression associated with headache  [13].There are strong relationship between tebsion headache and several psychologic factors are found but the exact role and influence on evolution of headache is not known . migraine is more often seen with anxiety and depression [14]. The author also emphasized depression and various pattern of headache  and how it affects daily living in indian subjects . He also expressed the out come with bidirectional relationship and protulate hypothesis which ways the treatment of headache in  depression and learnt the methodology of treatment with rational use of flunarizine and antidepressant especially SSRI .  The clinical use of the antidepressant signifies the relationship between headache and depression. Reduction of headache, pain reduces the depression which needs to further clarify. [11] The clinical use of migraine prohyaxis of flunarizine and SSRI Based on precedence to answer when and why use them in mono therapy or may be combination of both .

To evaluate role of flunarizine in treatment of depression and its ability to prevent or transform migraine into depression

Tools – HAMD rating scale and headache format of questionnaires

screened and selected patients who scored more than 9 on HAM-D  scale and has complaints of headache irrespective of headache characters into three designed groups on the basis of three questions - which comes first headache or depression or unable to recall .Put them into three groups and treat them with frunarizine , sertaline and combination of both respectively for four weeks .The test applied to measure score of depression  on Halminton depression rating scale and headache on  arbitrarily design format for assessment of headache on three domains such as 1) headache itself , 2)  severity of heache and 3) duration of headache in yes /no format .The two consecutive scores were taken one at time of visit as base line and another at the end of treatment at 4th week . The obtained data were analyzed and compared among groups and to other groups also

Group –A contains no of patients who answered depression came first and headache later to depression were treated with sertaline 50 mg /day at bed time

Group – B contains no of patients who answered  headache came first and depression later to headache were  treated with flunarizine 10 mg /day in morning in  day hr.

Group –C contains no of patients who answered unable to tell which came first

were  treated with sertaline 50 mg / day  plus flunarizine 10 mg /day 12 hr apart.

Total selected patient who scored more than 9 on HAM-D scale and complaints of headache were 58 in number out which 22 were droped and rest 36 were continued in study till completion of 4 week . At start of study there were measured on HAM-D scale and headache assessment format at the end of treatment same were applied and in  addition looked for treatment response of headache on  three questions 1)  remission of headache i 2)  remission of severity of headache 3) remission of duration and frequency of headache.
Group A had 21 patients of mean age  of 33.904 sd= 9.449.Among them 9 were male , 12 were female , 19 were Hindu and 2 were Muslim HAMD Score mean before and after treatment with SD of 22.76 SD=4.96 and 5.50 SD= 2.16, SEM before treatment = 1.108 . SEM after treatment =0.48 , CD = 19 ,CI=85% SE  of difference of mean=  1.137 , t test score = 15.444 , P <0>

Fig -1 Socio demography

Group B had 12 patients of mean age  of 31.5 04 SD= 9.496.Among them 2 were male 10 were female , 8  were Hindu and 4 were Muslim HAMD Score mean before and after treatment with SD of 20.82 sd=5.53 and 5.55 SD =2.49, SEM before treatment = 1.60 SEM after treatment  =0.89 , CD = 15 ,CI=85% SE  of difference of mean=  1.876 , t test score = 7.8968 , P <0>

Group C had 3  patients of mean age  of 40 sd= 5.Among them there were no  male 3 were female , 2 were Hindu and 1 were Muslim HAMD Score mean before and after treatment with SD of 23 SD=3.29 and 6 SD= 1.41, SEM before treatment = 3.06 , SEM after treatment  =1 , CD = 17 ,CI=85% , SE  of difference of mean =4014 , t test score = 4.2353, P =0.241 S ( significant) headache response 3y at the end of treatment .

    FIG – 2 treatment response in group before and after tretment

Fig -3 HAMD score inall group after treatment

Comparison between GROUP A and GROUP B

 CD = 0.0500, CI=95%, SE of difference of mean = 0.922, t test score = 0.0542, P =0.9571 NS (NOT significant) headache response had no difference in treatment response

Comparison between Group A and Group C

CD = 0.0500, CI=85%, SE of difference of mean = 1.334, t test score = 0.378, P =0.7114 NS (NOT significant) headache response had no difference in treatment response

Fig -4 graph representing change statistical parameter of treatment response

Comparison between GROUP B and GROUP C

CD = 0.4500 ,CI=95% , SE  of difference of mean=1.882 , t test score = 0.2391 , P =0.8148 NS

(NOT significant) headache response had no difference in treatment response

  Fig-5 represent headache response of tretment in Y/N format

Flunarizine has adverse effect of depression and movement disorder in elderly population and other group (1-4) inspire of that the common sharing nature of migraine and depression and its bidirectional relationship is the basis of treatment benefit with flunarizine  (5-15). The treated group of 12 patients who had noticed emergence of headache before depressive symptoms had shown improvement of depressive symptoms as well as headache as extremely significant. Similarly those had depressive symptom preceding to somatic headache symptoms treated with sertaline also had the same results p<0>

Flunarizine can act as antidepressant in specific disease condition where headache and depression co exist and headache preceded depression Sertaline   alone can be used in treatment of depression and headache ? Migraine.Those who fails to tell which occurs first can be benefited by combination of these two .It also proves the bidirectional relationship of migraine and depression.The significance of the question which occurs first headache or depression or unable to tell will design on the basis of existing problem facilitate immunotherapy and cost effective.