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Serotonin Syndrome: Don’t Panic!

The FDA issued an alert yesterday about the possibility of serotonin syndrome when people on antidepressants use triptans. Yes, serotonin syndrome is potentially life-threatening. It is also rare under these conditions and is usually caused by high doses of meds.

“Serotonin syndrome can occur when medications are mixed; usually this would require a very high dose of an anti-depressant and injectable Imitrex.  Usual doses of SSRIs and oral or nasal triptans rarely cause the syndrome — there have only been a handful of cases reported,” said Dr. Christina Peterson, a headache specialist and founder of HEADQuarters Migraine Management and Migraine Survival, in an e-mail.

The February/March issue of the HEADQuarters newsletter describes serotonin syndrome, what causes it, its symptoms and who is at risk for it. The newsletter also lists the medications associated with serotonin syndrome.

If you check Google News for “serotonin syndrome,” you’ll find a long list of articles that will likely freak you out. Here’s the Associated Press release that most of the stories are based on. WebMD and the Mayo Clinic have stories that aren’t too alarmist. To really scare yourself, check out the FDA health advisory. It’s all the same information, it’s just presented differently.

If you think you may be at risk for serotonin syndrome, don’t just stop taking your antidepressants. Not only should you get your doctor’s input before making such a decision, you need to taper off antidepressants to avoid withdrawal symptoms (which can include nausea, dizziness, trouble sleeping, shaking or nervousness, sweating, trouble thinking and concentrating).

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News, News, News

There is never enough time for me to post about all that I want to write about. And there’s been a ton of headache news lately. Here are some highlights.

Detailed Results of Trexima Studies (the drug isn’t named in the study, but it looks like Trexima to me)

  • Neck pain and discomfort decreased significantly at two hours for the compound versus placebo in study 1 (35 and 44 percent) and study 2 (28 and 54 percent).
  • Sinus pain and pressure decreased significantly at two hours for the compound versus placebo in study 1 (19 and 33 percent) and study 2 (23 and 38 percent).(1)
  • More patients were pain free at two hours in both studies (52 and 51 percent) compared to placebo (17 and 15 percent) and sustained pain-free response was maintained for significantly more patients (45 and 40 percent), without the use of a rescue medication, to 24 hours, compared to placebo (12 and 14 percent).
  • The compound was effective in rapidly eliminating migraine pain, as measured by pain-free rates at 30 minutes, one hour, two hours and four hours.
  • Incidence of migraine associated symptoms (nausea, phonophobia (sensitivity to sound) and photophobia (sensitivity to light)) was lower with the compound than with placebo.
  • The compound was generally well-tolerated. In both studies, only nausea (3 and 4 percent) and dizziness (1 and 2 percent) were reported in at least 2 percent of patients who took the compound versus placebo (1 and 2 percent for nausea, 0 and < 1 percent for dizziness).

Confusion Over Safety Of NSAIDs For Pain Relief Leads Patients To Suffer In Silence
Almost two thirds of people surveyed (64%) said they were confused about what to take for pain relief because of conflicting information on drug safety that has emerged following the withdrawal of Vioxx (rofecoxib), a COX-2 selective non-steroidal anti-inflammatory drug (NSAID) . Around 4 out of 5 (78%) said they didn’t know enough about the risks and benefits of medicines, whether prescribed or bought over-the-counter. Almost half (47%) said they weren’t using any painkiller medication at all for a number of reasons. Some were concerned about side effects, often after reading worrying news stories about painkillers, some had been advised to stop medication by their PCP and some thought they could manage without them.

Triple Therapy Synergy for Frequent Severe Migraine (registration may be required to read this)
The combination of behavioral migraine management, preventive medication, and optimal acute therapy appears to provide a superior reduction in migraine activity measures, functioning, and quality of life compared with any one alone, according to a study presented at the American Headache Society meeting here.

For these patients, “effective migraine management may require three components: a tailored acute therapy, preventive medication and behavioral migraine management to get the optimal results,” said Kenneth Holroyd, Ph.D., a professor of health psychology at Ohio University in Athens, Ohio, in an oral presentation.

Overweight Kids More Likely to Get Headaches
Children with headaches are 36 percent more likely to be overweight, results of the new research suggest.

“The numbers tell us that being overweight may contribute to kids having more headaches, most often migraines,” said Andrew D. Hershey, M.D., Ph.D., director of the Headache Center and a pediatric neurologist at Cincinnati Children’s Hospital Medical Center. “There likely are a number of causes, including poorer general health, body stress, lack of exercise and nutrition. It may not be that being overweight directly causes migraine, but that the reasons for being overweight cause these children to have worsening headaches.”

Magnetic Device Short-Circuits Migraine Headaches, Suggests Early Research
A hairdryer-sized magnetic device held briefly to the back of the head may short-circuit migraines before the pain starts, suggests preliminary research being presented at the 48th Annual Scientific Meeting of the American Headache Society (AHS).

People With Near-Daily Migraine Headaches Get Relief From Anti-Seizure Drug
An anti-seizure medication “quiets the brain,” providing relief to people with near-daily migraine headaches, suggest results of a randomized, multi-center study being presented at the 48th Annual Scientific Meeting of the American Headache Society (AHS).

FDA OKs the Pain Drug Opana
The drug, called Opana, is an opioid pain reliever taken by mouth. It will come in an extended-release form, called Opana ER, and an immediate-release version, simply called Opana.

The drugs contain oxymorphone hydrochloride, which was previously only available by injection. Endo Pharmaceuticals plans to relaunch the drug’s injected version for hospital use under the new trade name.

If you know of an article that I missed, please add it to the comments. Thanks!

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Trexima Study Presented at AAN Meeting

Just when I was ready to concede that Trexima might provide a migraine treatment better than existing meds, I read the fine print.

The articles say that 57-65% of participants who took Trexima, which combines Imitrex with naproxen (a NSAID, a relative to Advil), reported pain relief after two hours. In comparison, 50-55% of participants who took Imitrex and 28-29% who took a placebo reported relief after two hours. After four hours the percentages rose to 72-78% for Trexima, 61-66% for Imitrex and 37% for the placebo.

The treatment that most accurately compares to Trexima is Imitrex taken simultaneously with naproxen. Why wasn’t this combination studied? My guess is that including this comparison wouldn’t show enough of a difference between the two treatments to justify the FDA approving Trexima as a new drug. Thus, not allowing GSK to continue holding the Imitrex patent.

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Triptans at a Glance

Anyone who has been diagnosed with migraine without being told about triptans has been done a disservice. In my non-medical opinion, unless a person has an underlying medical condition that would making the medication dangerous, like stroke, uncontrolled diabetes, high blood pressure or heart disease, they should try at least one triptan.

The gold standard migraine abortive, triptans can work like magic for some migraineurs. They don’t work for everyone, but are helpful for many and can abort the migraine entirely before it begins. For others, the effect isn’t miraculous, but the reduction in intensity or severity of their migraines is still significant. It’s also worth noting that a lot of people have to try several different triptans to find the one that works for them.

There are seven different triptans. Imitrex was the first on the market and is the one people are most likely to know about. The others are Amerge, Axert, Frova, Maxalt, Relpax and Zomig. If you can’t keep a pill down, some are available as injections, suppositories and nasal sprays. Remember, though, that even triptans can cause rebound headaches.

To learn more about the drugs and how they work, see WebMD’s terrific article.

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Details on 4 mg Dose of Injectable Imitrex

Help for Headaches has an in-depth post on Imitrex, including the drug’s history and the benefits of the new 4 mg injection. Teri puts my sparse post to shame!