Serotonin Toxicity

Acute and preventive treatment of migraine

PURPOSE OF REVIEW

Migraine remains underdiagnosed and undertreated despite advances in the understanding of its pathophysiology and management. This article focuses on acute and preventive treatment of migraine, including the mechanisms of action, dosing and side effects of medications, and strategies for the most effective care.

RECENT FINDINGS

Best practice suggests that acute migraine treatment should be stratified based on the severity of the individual event, with a goal of returning the patient to full function within 2 hours of treatment. Migraine prevention strategies continue to be underused in the United States. More than 1 in 4 patients with migraines may be candidates for preventive therapy. To obtain the best results from preventive therapy, slow titration to an adequate dose for an adequate timeframe with good documentation of the results is recommended.

SUMMARY

This article reviews several options for managing acute attacks, including information on expected efficacy, dosing, and adverse effects. Strategies for effective application of acute therapies are discussed. Prevention can be added to acute therapy depending on headache characteristics such as frequency, severity, disability, and the presence of comorbid conditions. The mechanisms of action of preventive medications and strategies for their most effective use are discussed.

Triptans, serotonin agonists, and serotonin syndrome (serotonin toxicity): a review

The US Food and Drug Administration (FDA) have suggested that fatal serotonin syndrome (SS) is possible with selective serotonin reuptake inhibitors (SSRIs) and triptans: this warning affects millions of patients as these drugs are frequently given simultaneously. SS is a complex topic about which there is much misinformation. The misconception that 5-HT1A receptors can cause serious SS is still widely perpetuated, despite quality evidence that it is activation of the 5-HT2A receptor that is required for serious SS. This review considers SS involving serotonin agonists: ergotamine, lysergic acid diethylamide, bromocriptine, and buspirone, as well as triptans, and reviews the experimental foundation underpinning the latest understanding of SS. It is concluded that there is neither significant clinical evidence, nor theoretical reason, to entertain speculation about serious SS from triptans and SSRIs. The misunderstandings about SS exhibited by the FDA, and shared by the UK Medicines and Healthcare products Regulatory Agency (in relation to methylene blue), are an important issue with wide ramifications.

Serotonin syndrome risks when combining SSRI/SNRI drugs and triptans: is the FDA's alert warranted?

In 2006 the Food and Drug Administration (FDA) issued an alert, based on 27 case reports gathered over a 5-year span, regarding serotonin syndrome resulting from concurrent use of either a selective serotonin-reuptake inhibitor (SSRI) or a selective serotonin/norepinephrine reuptake inhibitor (SNRI) with a triptan. These diagnoses have been subsequently challenged as not meeting validated criteria for serotonin syndrome, in part because the FDA has yet to publicly disseminate important case report data. As a result of the FDA's alert, some clinicians are reluctant or refuse to provide these drugs concomitantly to patients. We believe that withholding these medications due to fears of serotonin syndrome is difficult to justify. In contrast to the small number of case reports, research shows that approximately 700,000 patients annually take SSRIs or SNRIs with triptans and that this drug combination has been effectively used by millions of individuals over the past decade. We encourage healthcare professionals to familiarize themselves with data on serotonin syndrome and to administer SSRIs/SNRIs with triptans when clinically appropriate.