SSRIs and migraines - desperate and need some educated views

[m.ninehouser]

hello. i'm a 26 year old male and i've been a classic/complicated migraine sufferer for about 12 or so years now. my migraines were awful during my teens in terms of intensity and frequency and then they began to slow down in my early 20s. i started effexor xr around 2003 due to worry and anxiety about migraines. i had noticed, whether it was the medicine or not, that my migraines calmed down. i maybe got 2 to 3 a year for the next 4 years and the intensity level was much more tame. i could just sit in a dark room and wait through them with no pain killers.

around may of 2007, i tapered off of effexor over the span of a month (i think) and really had no withdrawal effects save the brain zaps and maybe a little nervousness. i had one migraine attack in or around august and it was the same kind of migraine that i'd get for the past 4 years; bearable. then around october, i began getting really anxious again, even depression coupled it this time. i think this was because i was out of college and in between jobs and out on my own, and i had no idea it'd be so stressful and worrisome. no matter what the reason is, i saw my physician and he put me on 20mg of citalopram (celexa). i didn't begin taking the medication until november 22nd. i had noticed about 3 or 4 weeks into the treatment that my anxiety was getting much more bearable, and the depression was pretty much surpressed. but then about 5 weeks into the treatment, once the medication was really kicking in, on january 1st i woke up with a migraine. this didn't bother me as i figured i was due for one since august. i then got one 3 days later. then ten days or so after that i got one again and then another one the very next day. naturally, toward the end of january i began tapering off of citalopram assuming it was the cause. i tapered to 10mg for a week, then to 5mg before the double-migraine i just mentioned hit and then after that i just quit 5mg abruptly after 4 days. so i only took 11 days of cutting my dosage before i stopped completely. this may have been a bad idea.

about 2 weeks after quitting the 5mg, i got an odd migraine that began with word-salading, which was usually a symptom of a migraine i rarely got, and if i did, it was an hour or two into the migraine, after the headache started. anyway i was terrified and went to the er and had a ct scan done and a cardiogram. big surprise, i was fine. 'just migraine patterns' the doctor said. -- i feel it's also important that i mention that after i was off of citalopram completely i started taking a synthetic multivitamin daily.. i've heard this can be a bad move for people who had adverse effects with ssris. i'm since stopped. -- anyway, two weeks or so later i had another migraine and then another and another... basically i just had my tenth migraine in 2 and a half months. i had only gotten 3 a year.. i can't seem to logically justify this drastic change on anything else but an adverse effect to the ssri and now maybe ssri discontinuation syndrome.. the only other factors that occured during this time was that i lost around 30 pounds over 4 or 5 months and the weather was pretty wacky this winter around pittsburgh. but i've gone through the past 4 wacky winters just fine... anyway, i suppose i'm just looking to hear that my theory is valid and that my migraine patterns could go back to normal to where they were inbetween effexor and celexa, virtually non-existent. although, of course i want to hear the truth; maybe migraine patterns in males change in their mid-twenties and i'm unaware. the main problem is, i don't have health insurance to really get this looked at just now so i'm rather desperate for clues here... i thought my migraines going from bad in my teens to less frequent in my twenties was the only pattern change i could expect until later life, but maybe i was wrong. - anyhow, any advice that i could get or any insight would be more than invaluable for me. i really, really appreciate you taking the time to read this, i know it was a long one... thanks so very much.

-m. ninehouser

[clinicalguru3]

Have you ever been given prophylactic (preventative) treatment.

Examples could include topiramate, valproic acid, amytriptyline or beta blockers?

How is your sleeping?
Have you completed a headache diary?

You can download one here..

http://www.asktheneurologist.com/headache.html

it is very useful when visiting a headache specialist to go with a filled-out headache diary.

You can go through our headache diagnosis program here to check there are no surprises regarding the diagnosis:-

http://www.asktheneurologist.com/diagno ... -type.html

looking forward to hearing from you.

[m.ninehouser]

thanks so much for the reply...

i have tried preventatives in the past and would like to avoid taking any type of preventative medication whatsoever if at all possible... none of them really helped me at all. i've not tried beta blockers yet though. i'll honestly only be open to the idea of getting on meds once i find out that these won't subside. i have no health insurance just now, so what i'm mainly seeking is peace of mind that my migraines could be exacerbated by my recent use and discontinuation of citalopram. i mean is it normal for someone in their early twenties who went from a ton of migraines in their teens, to barely any for several years, then to 10 in 2 months all of the sudden? i suppose i just can't escape the logic of it being the ssri...

my sleeping is fine as far as i know. though i know that generally when i wake up in the morning, i want to go back to sleep because i'm tired and not get up.. so i suppose i don't quite feel 'refreshed' upon awakening. but i don't wake up in the middle in of the night save to change position. nor do i suffer from insomnia or anything like that.

just now i'm keeping a diary of sleeping patterns, food i eat, and the weather conditions daily.. though i've only started that at the beginning of march.

i'm going to try this diagnosis program now...

eager to hear back!

-m. ninehouser

[clinicalguru3]

How many hours sleep are you receiving each night?

Is it right to say you have received all the drugs I mentioned except for the beta blockers?

If so at what doses and for what period of time?

[m.ninehouser]

well i honestly can't say i tried all of those you mentioned. i was only around 15-17 when i tried preventative stuff. i wish i had kept a better record of this sort of thing when i was younger... i definitely remember trying the herbal remedy feverfew for certain. come to think of it, most of the meds i took in my teens may have been abortive. i tried maxalt, imitrex, migrainal (is that one?) - the only preventative i remember being told would help was effexor xr. my doctor said it would lower my hightened anxiety and in some cases helped patients who had chronic migraines. - i began taking effexor in 2003 and didn't stop until may of 2007.. so rather recently. but i guess it should be noted that while on effexor i had very few migraines. though, i was off effexor for 8 or more months until i started citalopram and i had still only received one migraine..

in terms of sleep, i get at least 6 always but usually 7-8. once in a while i'll get 9-10. but it's almost always between 7 and 8.

[clinicalguru3]

OK....there are quite a few options then.

First thing..did you use the diagnosis program at

http://www.asktheneurologist.com/diagno ... -type.html ?

I assume you have had a full neuro exam which was normal including checking the eyes with an "ophthalmoscope"...please confirm that this is the case and that let me know what the diagnosis program said.

[m.ninehouser]

all i've had done recently is a ct scan of my head and a cardiogram.. i do not have insurance to see a nuerologist just now. i had a stand eye exam done before receiving new glasses about 5 months or so ago and everything checked out quite fine. as i previously stated, my blood work and thyroid test all came back spick and span as well as my ct results and my cardiogram.

i did run the diagnostic program and i'm a little confused as to the answer i was supposed to recieve. after entering in my age these migraines began (14) and clicking that they come on suddenly and worsen over hours or days or months, it brought me to a page that told me i had 'headache.' then it listed the possible 'primary h-aches' such as cluster headache, migraine, migraine aura, and tension.. i'm not quite sure what this means in terms of a result. i definitely know that i suffer from migraine with aura and i have reason to believe that i suffer from complicated migraine with aura as sometimes the aura lasts longer than an hour or will return briefly again in the midst of the headache itself.

i'm sorry i don't have more medical-type information to share with you. with no insurance and an outrageous ER bill, i have very little options. my main concern here was to find out if taking ssris and tapering off of them too quickly can be a justifiable cause of migraine frequency increasing almost ridiculously like they have for me.

[clinicalguru3]

In that case I will respond to your question on the assumption that the diagnosis of migraine is not in question.

1) Yes...changing SSRI medication can affect migraines, either directly through the effect on neurotransmitters or indirectly through the effect on quality of sleep, mood etc.

2) Non-medical measures you could use to decrease the migraine frequency include:-

a) Relaxation techniques / decrease stress levels
b) Ensuring you get 7-8 hours of sleep every night
c) Medical preventative treatment (e.g. topamax, beta blockers or valproic acid.)

Hope that helps,

Please update us on our progress

[m.ninehouser]

that is a relief to hear... i have a follow-up question if you don't mind elaborating on your answer.

in your professional opinion would you say it makes sense that my migraine pattern is being affected by the ssri and then the abrupt discontinuation of the ssri or that this is just a natural migraine pattern change? i mean is it normal for a male in their mid twenties to go from 2 migraines with aura a year to 10 in 2 months? or does something that drastic say to you that there's an outside factor triggering them or that it's just my brain evolving my migraine patterns? since i can't see a specialist just now i'm left to only speculate what makes sense; which is that the medication, because it coincides so perfectly with my new migraine frequency, being the cause. however, i don't know if this is something that neurologists see every day. maybe it's normal for a male getting migraines in their adolescence to have them taper away for a few years in their early 20s and then have them return even worse than they were in adolescence... i'm sorry i'm babbling, i guess i'm just desperate to hear what makes more sense to a professional is all... do migraines usually change this drastically in frequency?

my sleep and mood and the like wasn't effected by the ssri or the discontinuation just for the record so i'm assuming if it is the drug, then it's what it's doing to my brain that is causing these.

-m.

[clinicalguru3]

Well...there is no way of knowing for sure (as often migraines get worse with no obvious reason)..but I have come up with a theory.

I think that the vanlafaxine (effexor) was preventing your migraines and that the citalopram (celexa) was either having no effect on the migraines or, was also effective, but to a lesser extent than the effexor.

Thus:-

1) Effexor was controlling your migraines.
2) The preventative effect of effexor can take a long time to ware off and may have extended into the time you started the citalopram.
3) The citalopram may have helped a bit, explaining why they got worse after stopping the citalopram, or may have had no effect whatsoever and the worsening was all due to a combination of stopping the effexor (which probably helped quite a bit) and the normal "random" patterns.

I will back up my answer you by referring to some research articles:-

The effect of venlafaxine on migraine

Headache. 2005 Feb;45(2):144-52.


The efficacy and safety of venlafaxine in the prophylaxis of migraine.
Ozyalcin SN, Talu GK, Kiziltan E, Yucel B, Ertas M, Disci R.

Department of Algology, Istanbul, Turkey.

OBJECTIVE: To evaluate the efficacy and safety of venlafaxine in the prophylaxis of migraine. BACKGROUND: The efficacy of venlafaxine, which is selectively effective on the serotonergic and noradrenergic mechanisms, on various headaches and chronic pain syndromes has been demonstrated. To our knowledge, this is the first placebo-controlled, double-blind, randomized study of two different doses of venlafaxine for migraine treatment. METHODS: In this prospective study, 60 migraine patients without aura were randomly assigned to venlafaxine XR 75 mg, venlafaxine XR 150 mg, or placebo. The frequency of headache attacks, the severity and the duration of attacks, and analgesic use were monitored every 2 weeks for 2 months. Adverse events and patient satisfaction were also evaluated during these visits. At the end of the 2 months, global efficacy and tolerance were investigated. RESULTS: A significant difference was observed between the venlafaxine 150 mg and placebo groups in the number of headache attacks (P= .006). According to patient satisfaction comparisons, the active drug groups were significantly different when compared with placebo (P= .001 at visit 2 and visit 6). When the global efficacy was considered, 80% of patients in the 75-mg group and 88.2% of the patients in the 150-mg group evaluated treatment benefits as either good or very good. CONCLUSIONS: Venlafaxine was more effective than placebo and is safe and well tolerated as migraine prophylaxis.

The questionable effect of citalopram on migraine...the first article showing a positive effect triggered a letter to the editor reporting an actual worsening of migraines with aura presumed to be due to citalopram.


Neuropsychobiology. 2004;50(4):322-8.

Comment in:
Neuropsychobiology. 2007;55(2):121-2.

Evaluation of the prophylactic efficacy of amitriptyline and citalopram, alone or in combination, in patients with comorbidity of depression, migraine, and tension-type headache.
Rampello L, Alvano A, Chiechio S, Malaguarnera M, Raffaele R, Vecchio I, Nicoletti F.

Department of Neurosciences, University of Catania, Catania, Italy. rampello@unict.it

Antidepressants are used to treat chronic daily headache disorders such as migraine and chronic tension-type headache (TTH), which are often associated with depression and anxiety. Here, we studied the efficacy and tolerability of amitriptyline and citalopram, given alone or in combination, in patients with 'triple' comorbidity of depression, TTH, and migraine. Eighty-eight patients were enrolled in the study and randomly divided into two groups. The first group received amitriptyline and the second citalopram for 16 weeks. Patients were assessed at weeks 0, 4, 8, and 16. The two drugs were equally efficacious in relieving depressive symptoms, although amitriptyline was more efficacious than citalopram in reducing migraine and TTH attacks. Patients who did not respond to monotherapy (<30% of improvement in the clinical scores) were treated with a combination of the two drugs for 16 additional weeks. In these selected patients, the combined treatment produced a substantial improvement in depression, migraine and TTH without producing major side effects such as those commonly related to the 'serotonergic' syndrome. The results indicate that a combined therapy with amitriptyline and citalopram may be particularly beneficial for patients with TTH, migraine and comorbid depression that do not respond to monotherapy.

Migraine with Aura Triggered by Citalopram.
Neuropsychobiology 2007;55:121-122


Hope that helps!

[m.ninehouser]

i had actually considered this theory at a previous point but was told that the effexor benefits were well out of my sytem within 5 months after stopping it in may of 07.. you do, though, have reason to believe that the the effexor could have conditioned my brain in such a way that it continued to combat migraines for 8 months until i started citalopram? in other words i should consider the 8 months i was off of effexor as only being migraine-free due to having been treated with effexor for 4 years and not having it out of my system fully?

i have considered getting back on my 150mg of effexor more than once but probably won't for a few more months. this is only because i want to wait out the possible time frame of ssri discontinuation syndome after taking the citalopram. you consider your theory to be more likely than just celexa messing up my brain chemistry and my brain still not being back to normal though? because i'd really rather not get back on effexor if i can help it. i was told being on any anti depressant for too long is a bad idea, and 4 years, i was told by a physician or two, was already too long... thanks for this info; i'm looking forward to hearing back!

-m.

[clinicalguru3]

This is just speculation but I think that it is likely that the effexor was damping down your migraines, and although the physical effects had probably left your system, it may have taken a couple of months until the exacerbation occurred (for reasons we will never know).

In other words you may have been destined to have a bad period every few months but escaped these periods whilst taking effexor.

The worsening after stopping citalopram may just represent a "bad patch" or may be directly related to stopping the drug.

If the latter is true then they should improve within a few weeks.

Hope that helps

[m.ninehouser]

it does help. quite a bit. so do you think it's a safe bet to wait it out a couple more months and then if the migraines persist, try getting back on effexor? will the drug likely have the same positive affect on my migraines even after attempting citalopram and failing? or should i give it much longer before trying a drug again?

idealy i'm hoping that the celexa and then the discontinuation of it is the entire cause of my new frequency pattern, but i suppose it does make sense to not rule out that the effexor had something to do with it, seeing how i had taken it for so long and all..

would you happen to have any links or citations of clinica articles regarding the effects of effexor after discontinuation and how long they could last in the body and brain by chance? i'd find that more than interesting to leaf through. i guess i'm just hoping that i could find something that would leave me to believe that i did have a few natural months of being migraine free without effexor's help before i started celexa...

-m.

[clinicalguru3]

If the issue is simply migraine prevention then I would try beta blockers / topamax / depalept depending on your specific situation rather than effexor.

If mood / anxiety issues are important then your doctor may consider effexor as it probably helped you in the past.

The page http://www.asktheneurologist.com/migraine-therapy.html has links to a wide selection of migraine therapy articles.

The articles at the bottom of the page relate mainly to effexor.

It is an rss feed so you can keep checking back to see if there are any research updates.

Thanks for being in touch....hope you get and stay well and please givce us an update letting us know what treatment protocol you get prescribed.

All the best

[clinicalguru3]

If the issue is simply migraine prevention then I would try beta blockers / topamax / depalept depending on your specific situation rather than effexor.

If mood / anxiety issues are important then your doctor may consider effexor as it probably helped you in the past.

The page http://www.asktheneurologist.com/migraine-therapy.html has links to a wide selection of migraine therapy articles.

The articles at the bottom of the page relate mainly to effexor.

It is an rss feed so you can keep checking back to see if there are any research updates.

Thanks for being in touch....hope you get and stay well and please give us an update letting us know what treatment protocol you get prescribed.

All the best