Headache News

Should triptans be taken with certain antidepressants?

In 2006, the FDA put out a warning about triptan medications (Imitrex, Maxalt, Relpax and other migraine-specific medications) being taken with SSRI's (antidepressants such as Prozac, Lexapro, Celexa, Zoloft).  The concern was that the combination would cause an unusual but dangerous set of symptoms called Serotonin Syndrome.  This syndrome involves autonomic changes in the body and can cause confusion, seizures, blood pressure problems, dilated pupils, and other symptoms.  It can be life threatening.  As a result, pharmacies have been warning numerous patients and doctors about this issue and it has been causing significant fear among migraine patients and their doctors.

In an excellent talk, Dr. Stuart Tepper (a well-known migraine researcher) puts these concerns to rest.  Indeed, by his analysis, those patients who were on the combination of SSRI and triptan had a lower incidence of Serotonin Syndrome than those who were on an SSRI alone.  He also points out that, based on the ways these drugs work (their mechanisms of action), no fear of the combination should have been a concern for the FDA.

The bottom line?  While SSRI's can rarely cause Serotonine Syndrome, there is no increased risk in taking an SSRI and a triptan medication.

Migraine Benefit from Forehead Lift

 

It has recently been reported that a plastic surgeon has a technique for improving migraines.  The surgeon operates around the supraorbital nerve in something called a forehead lift.  He is removing a portion of the corrugator muscle on each side.  It was originally being performed for cosmetic benefit, but many of his patients commented on a migraine benefit.  You can read a brief summary of the surgery study here.

Commentary:

It is intruiging to think that such a simple technique could have such a large benefit.  It is also surprising.  I would expect that some patients with supraorbital nerve irritation would get benefit, but not the high rate of response that this surgeon is obtaining.  In our office, we sometimes refer patients for surgical release of various nerves, including occipital, supraorbital, or zygomaticotemporal.  There is varying success with these procedures.  In addition, we administer Botox to some patients, which may have a similar effect of reducing muscular tension around the nerves, making them less painful.  (Really, though, this is speculation, as the mechanism by which Botox may help migraine is not known). 

In this plastic surgeon's study, some patients got the real surgery and others got shame surgery - during which an incision was made but the muscle was not cut.  One question is, does the shame surgery he performed result in the reducion of frown lines?  If not, then the surgery would be considered 'unblinded', meaning the patients are able to determine who had the real surgery and who did not.  This can lead to a placebo effect, in which patients who get the active treatment expect (and experience) better outcomes.  In addition, those who get the real procedure may feel better about themselves and their appearance, reducing their stress levels, resulting in fewer migraines.  Still, if this last is the case, it wouldn't be a bad thing!  Overall the result is impressive and deserves serious consideration.