10.2217/PMT.11.1 Pain Manage. (2011) 1(2), 99–101 99 The evidence that tricyclic antidepressants (TCAs) are effective for the management of pain is incontrovertible. TCAs, and in particular amitriptyline, have more studies demonstrating effectiveness for a broader range of pain syndromes than any other treatment modality. The evidence is strong and consistent across different classes of pain. In a series of meta-ana lyses, we found that TCAs are effective in the treatment of back pain [1], idiopathic pain [2], fibromyalgia [3], functional gastrointestinal disorders [4], chronic fatigue [2], tinnitus [2], tension headaches [5] and, most recently, migraine headaches [6]. While TCAs have generally been reported to be effective in a broad array of pain syndromes, the evidence for effectiveness in neuropathic pain is particularly strong [7,8]. However, while effective, the use of TCAs for pain is not as common as it should be [9]. This is because there are a number of barriers to their use. TCAs have a number of side effects. In our recent ana lysis, we found that patients taking TCA, compared with placebo or selective serotonin reuptake inhibitors (SSRIs), were more likely to experience drowsiness and a dry mouth [6]. Other side effects commonly attributed to TCAs, such as dizziness, constipation and blurred vision, occurred no more commonly than either placebo or SSRIs. The side effects from TCAs tend to decrease over time and can be reduced if the medications are titrated. However, for many pain syndromes, alternative treatment modalities have a reputation for having fewer side effects. Consequently, many providers turn to other agents as their first-line therapy; for example, topiramate or neurotin for headaches. Interestingly, in our studies, we have consistently found no difference in the rate of patient withdrawal from treatment between TCAs and other modalities, including placebo or SSRIs, and some side effects attributed to TCAs were no more common than in placebo. It is likely that many of the reputed side effects from TCAs are overstated. Another barrier is that, while TCAs are effective, they are not a panacea. TCAs have consistently resulted in a twofold increase in the odds of experiencing at least 50% improvement. The amount of pain reduction has been demon strated to be large (~2 standard deviations). TCAs reduce pain, but