Headache © 2010 American Society Published by John Wiley & Sons, Inc. doi: 10.1111/j.1526-4610.2010.01692.x HEADACHE Toolbox

Triptans, SSRIs/SNRIs and

Syndromehead_1692 1101..1102

Serotonin is a naturally occurring depression). The simultaneous administration “messenger” protein that is found primarily in of two drugs that promote serotonin’s activity the gastrointestinal system, certain blood cells theoretically could produce an acute (platelets) and the central overabundance of the protein and a (brain and brain stem). Abnormal activity of this constellation of symptoms termed “serotonin messenger protein has been implicated in both syndrome.” and depression, and that modify serotonin can be effective in treating The most common symptoms of serotonin both disorders. Such medications include, for syndrome include skin flushing, , rapid migraine, the “”: eg, heart rate, elevated , (Imitrex, Sumavel, generic sumatriptan); and, and...yes, headache. for depression, the selective serotonin Because of this potential risk, the federal reuptake inhibitors (SSRIs) and selective Food and Drug Administration issued a serotonin/ reuptake inhibitors warning that implied doctors and patients (SNRIs): eg, fluoxetine (Prozac or generic should be wary of the co-administration of a fluoxetine) and others for the SSRIs, and and an SSRI or SNRI. In fact, this (Effexor or generic venlafaxine) and warning was based almost entirely upon a others for the SNRIs. theoretical concern and not upon clinical Because migraine is “co-morbid” with evidence or scientifically derived clinical depression (ie, each disorder occurs more evidence. Clinically significant serotonin frequently in individuals afflicted by the other syndrome from simultaneous use of these condition than it does in the general medications appears to be extremely rare and population), many patients may be prescribed may not be caused by the triptans at all, and both a triptan (for acute migraine treatment) the benefit of adequate treatment for both and an SSRI or SNRI (for chronic treatment of migraine and depression appears to far

1101 1102

outweigh the exceedingly low risk of ask your healthcare provider. Regardless, the dangerous “serotonin overload.” use of and triptans together appears clinically justified. Whether one is also taking an SSRI or SSNI or not, this should not be taken as a John F. Rothrock, MD green light for indiscriminate use of the Editor-in-Chief, Headache triptans. There are clearly defined limits as to Director, Headache Treatment how often one may use triptans for acute and Research Program headache treatment, and to exceed those University of Alabama limits is to risk a variety of medical Birmingham, AL USA complications. Know the limits. If you don’t,