Serotonin Syndrome: Are Triptan Users Really at Risk?

Back in 2006, the FDA in the USA issued a warning about using triptan medications along with certain antidepressants because of the risk of serotonin syndrome. But how high is the risk? New studies suggest that the risk is extremely low, and that thousands have been mixing the medications with no problem.

What is the concern?

Serotonin syndrome can be serious, even fatal. It is caused by excessive accumulation of serotonin, and important neurotransmitter, in the body. Some medications and herbs have been associated with the problem, the idea being that they work to cause runaway levels.

This includes triptans, commonly used for migraine, and certain antidepressants – selective serotonin reuptake inhibitors (SSRIs) and selective serotonin/norepinephrine reuptake inhibitors (SNRIs).

There has been some suggestion that triptans alone could lead, in rare cases, to serotonin syndrome.

This is an important question, because many migraine patients also suffer from depression. And to be clear, for most migraine doctors, this was a “use with caution” warning, not a prohibition.

Re-evaluating the Research

Just because there is a “risk” doesn’t mean you should avoid something. Just because you have a “risk” of falling down the stairs, doesn’t mean you avoid stairs.

So here’s the question – just how high is the risk?

Researchers in Houston in the USA went back to check out the original research that the FDA had in 2006. They found that the evidence should not have been considered sufficient for the FDA warning. The evidence was “Class IV” – the lowest possible level. (See the abstract here: The FDA alert on serotonin syndrome)

Another study, presented at the 59th Annual Scientific Meeting of the American Headache Society, provided even more reason to question the warning. Over 14 years, about 19,000 patients who used both triptans and SSRI or SNRI antidepressants were evaluated – and between 4 and 7 patients developed serotonin syndrome. That’s about a 0.03% risk.

Of those patients, how serious was their condition, and do we even know for sure that it was caused by the medications? Serotonin syndrome, although it can be serious, usually is not fatal.

Of those patients, only two cases were related to triptan medications. And in one of the cases, the symptoms started before the patient took the triptan!

In the end, one of the researchers said simply,“Our data do not suggest a clinically meaningful risk of serotonin syndrome in patients coprescribed triptans with SSRI/SSNI antidepressants.”

Read more about this report: Triptans, Antidepressants, and Serotonin Syndrome: How Real Is the Risk?


From these studies, it seems that with regular use of triptans and antidepressants, the risk is almost nil. However, because of the seriousness of serotonin syndrome, patients should be aware and should report new symptoms to their doctor. It is also important to remember that there is concern about “street drugs”, taking more than is prescribed, and certain supplements such as St. John’s wort and ginseng. Your doctor needs to be aware of what other drugs and supplements you’re taking.

For more information on the drugs that have caused concern, see Serotonin Syndrome: Symptoms and causes.

via: Triptans (like Imitrex) mix well with antidepressants


The Link between Skin Rashes and Migraine

If you suffer from both skin rashes and migraine, you’re not alone. And there may be an important connection between the two which we need to research.

Psoriasis (the “p” is silent) is a common skin disease, probably affecting about 1-2% of the population. There are various types of psoriasis, but it often shows up as red, scaly patches of skin. It can also show up in nails, or even as stiff joints. It flares up at various times, and can be either a small annoyance or a major condition.
Migraine, Psoriasis, and Heart Disease
Psoriasis can run in families, but it can also be brought on through an infection, obesity, and smoking.

A recent study in Italy found that people with psoriasis, women especially, were extremely likely to also suffer from migraine. Most often this was migraine with aura, but migraine without aura showed up very often as well.

Why the connection, and why should we care? Well, researchers suspect a biological relationship between the two, but further research will need to be done. Migraine is often associated with autoimmune diseases such as psoriasis, so in a way this isn’t a surprise.

But perhaps the biggest concern that researchers had is the link between both psoriasis and migraine – and heart diseases. Psoriasis itself, and perhaps even some of its treatments, can significantly increase the risk of high blood pressure, irregular heartbeat, and stroke, for example. Migraine also increases your risk of cardiovascular disease. So having both may increase your risk even further.

Be sure you tell your doctor if you notice symptoms of psoriasis. There are helpful treatments. You may want to especially consider having some good tests done on your levels of vitamin D. Omega-3 supplements may also be helpful for both migraine and psoriasis. You will also want to take a look at your risk of heart disease (read Migraine and Heart Disease: 7 Critical Things to Know Now).

There are a wide variety of treatments for psoriasis, as there are for migraine. Your doctor will help you decide which are best for you. Being aware of both diseases will help you assess symptoms and find treatments that work.

For more information:


Zembrace SymTouch: A Surprising Advance in Migraine Treatment

Once I start telling you about Zembrace Symtouch, which was approved by the FDA last year, you’re going to wonder why in the world it’s newsworthy in this world of new frontiers in migraine treatment. There are simply a lot of reasons not to like Zembrace – at first glance. But it just might surprise you, as it surprised me.

So with all the new treatment options out there, what if I told you that this new treatment is an injection, and worse, that it’s a retooling of an old migraine treatment – a triptan – the oldest triptan on the block – sumatriptan. Even worse, I’m going to tell you that the injection will give you less of the medicine than many have tried in the past.

See? I just lost half my audience. “I hate injections”“I already tried sumatriptan”“I need something stronger”

But for all the open-minded people who are still here, let’s take a closer look.

Zembrace SymtouchFor many people, taking an injection for migraine is like eating brussell sprouts is for me. I know it’s good for me, but it just ain’t happening. We know that migraine needs to be treated quickly, and medically speaking injections are an excellent way to get the medication quickly.

But more than that, many migraine patients suffer from forms of gastric stasis, which means that pills simply won’t get the medication into your system properly. So if you’ve tried triptans by the oral method and they haven’t worked, you may find that it’s just because they weren’t properly absorbed.

And when it comes to injections, Zembrace really is cutting edge. It comes in the form of a “pen”, single use, with the exact amount of medication you need built in. It also has the thinnest needle of all autoinjectors.

It’s so easy to use, it’s very hard to make a mistake. It’s quick, taking only a few seconds, and will get the medication working within 10 minutes (yes, some people actually start experiencing pain relief that quickly).

As regular readers know, a different triptan, or even a different “version” of the same triptan, can make all the difference. So it’s not surprising when someone who has tried sumatriptan before without success tries it again in a different formulation and finds that it works.

What is surprising is the dosage of Zembrace. Originally, sumatriptan was marketed in a 6mg dose. 4mg has been available for a while. But – 3mg?

Actually, studies have compared the 6mg dosage with the 3mg dosage. The results are not only comparable – in some cases, 3mg even performed better. And the patient may experience less side effects with the lower dosage (see notes below).

So Zembrace is worth a look if you suffer from migraine or cluster headache. Not only because it is easy to use and uses the best technology for treatment of its kind, but also because it may lead to more similar medications in the future.

Check out Zembrace Symtouch at the official website here.

Further reading:


“Out of My Head” is almost here – Have You Seen the New Trailer?

If you haven’t seen it already, don’t miss the new trailer for Out of My Head, a documentary about migraine that has been a long time in the making. The film, from filmakers Susanna Styron and Jacki Ochs, is currently scheduled to launch this fall.

Out of My Head was partly funded through Kickstarter – you can see “>the promotional trailer for that here as well.

The film promises to show aspects such as the history of migraine suffering, the economic cost, and the disabling nature of the disease, as well as personal stories and “a spotlight on the frontiers of neuroscience and the exploration of the brain”.

Check out the trailer below, and visit the official Out of My Head website here.


Glutamate Levels Higher in People with Migraine

Glutamate is a neurotransmitter that everyone needs, but its link with migraine has become well-known. It’s not surprising that there’s a connect – glutamate transmits pain signals in the body. And now we have more evidence that glutamate levels in the brain are higher in people with migraine.

BrainGlutamate has been a big topic in the world of migraine genetics, because genetic variants related to migraine may lead to a build-up of glutamate in nerve cell junctions in the brain. Many treatmente available or being developed for migraine today may affect glutamate messages in the body. This would include treatments focused on calcium channels (such as Verapamil) and the new CGRP inhibitors.

Glutamate may be a culprit in a number of disorders other than migraine – including Alzheimer’s, multiple sclerosis (MS), and autism.

It may seem obvious that a pain transmitter would be higher when someone has a severe headache. But this study says something a little different.

Published in July in the neurological journal Brain, researches discovered that glutamate levels were higher in the brains of people with migraine – specifically in the visual cortex. Surprisingly, that was specifically in migraineurs without aura.

But the most interesting fact of all was that these were interictal levels. In other words, the glutamate was higher in migraineurs than in the general population in between attacks – when no headache was present.

Could this be related to the higher “excitability” of the migraine brain, and why we’re more prone to headaches? The researchers think so.

To read more about the study, see the abstract here: Cortical glutamate in migraine

A lot of research is being done to see how various treatments, exercise, and even diet could improve glutamate levels. But the answer is not simple, because glutamate levels are a part of a complex web of activity in the brain. But studies like this are giving us a better understanding of migraine, and giving us more evidence that glutamate plays a key role.

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