Use in Adults
Antidepressants
THIS GUIDE PROVIDES A PARTIAL LISTING OF PRESCRIBING INFORMATION FOR THIS MEDICATION. FOR A FULL LISTING OF PRESCRIBING INFORMATION PLEASE REFER TO THE PACKAGE INSERT. CLICK ON THE BRAND NAME® TO VIEW THE LINK TO THE PACKAGE INSERT.
TCAs
amitriptyline (Elavil®) Click Here to expand or Contract
Brands:
- Elavil® (amitriptyline) For Complete Prescribing Information Click Here for the Package Insert
- 10, 25, 50, 100, 150 mg tablets
- 10 mg by mouth at bedtime
- For patients particularly susceptible to side effects, consider starting with ½ of a 10mg tablet and dosing earlier in the evening (e.g., 7pm)
- 10-150 mg by mouth at bedtime
- Some experts suggest that a lower maintenance dose range of 20 -50 mg once daily at bedtime due to tolerability
- First office visit:
- 10 mg by mouth at bedtime
- Increase to 20 mg by mouth at bedtime at 2 weeks if not having intolerable side effects
- Tell the patient that if they cannot tolerate a particular dose then reduce the medication to the previous dosage that they were able to tolerate
- Second office visit (2 months after first visit):
- if satisfactory response (>50% decrease in the frequency of migraine days per month as compared to baseline) then continue 20 mg dose.
- If no satisfactory response, increase dose to 30 mg by mouth at bedtime for 2 weeks and then 40 mg by mouth at bedtime if possible.
- Tell the patient that if they cannot tolerate a particular dose then reduce the medication to the previous dosage that they could tolerate
- Dry mouth, dry eyes and sedation are the most common
- Less commonly can get constipation, upset stomach, sedation, and blurred vision
- Weight gain possible, but less likely with the lower dosages used for migraine prevention. Nevertheless, still need to monitor for weight gain.
- Considered one of “first line” preventives, which are a group of medications that are commonly recommended as initial therapy for those starting a migraine preventive for the first time.
- Beta blockers and topiramate are also considered “first line” preventives.
- Might use in the following patients:
- Those with insomnia, since amitriptyline may also be useful in treating insomnia
- Those who have attacks of tension headache. Amitriptyline is a first line therapy for prevention of tension headaches.
- Those with other pain disorders such as fibromyalgia, low back pain, occipital neuralgia or neck pain since amitriptyline may decrease the pain severity of those conditions as well.
- When considering a tricyclic antidepressant, generally the choice is between amitriptyline and nortriptyline.
- Might choose amitriptyline if they have insomnia and nortriptyline if they do not have insomnia.
- If patients are very sensitive to medication side effects, consider using nortriptyline, as it has a lower incidence of side effects.
- Main advantages of amitriptyline are:
- Good efficacy, long track record and low cost.
- Main disadvantages are:
- Side effect of weight gain (although less likely with lower dosages) and sedation.
- Avoid use in those with QT prolongation
- Some headache experts will obtain an EKG on all patients prior to start of amitriptyline to evaluate for QT prolongation.
- Others would obtain an EKG only in those at high risk for QT prolongation, which include patients with any of the following: 1) older age (e.g., ≥ 65 years of age), 2) past cardiac disease and 3) those receiving multiple medications that are known to prolong the QT interval.
- Might also consider an EKG to monitor for potential QT prolongation when higher dosages of amitriptyline are given (e.g., 50 mgs or greater).
- May consider a combination of amitriptyline with another migraine preventive to see optimal response in those with more frequent and/or disabling attacks of migraine.
- QT prolongation: QT prolongation particularly with higher dosages or if combined with other medications that prolong the QT interval. May need to check an EKG at baseline in those at risk for having QT prolongation. Avoid medication in those with QT prolongation
- Suicidal thoughts: Antidepressants have been associated with suicidal thoughts and behavior if used in adolescents and young adults
- Comorbid illnesses: Cautious use in the elderly as well as those with cardiovascular disease, urinary retention, bipolar disease, constipation and hepatic or renal disease.
- Pregnancy and Lactation: Consult package insert
- Bleeding risk: May increase the risk of bleeding if combined with antiplatelet meds or anticoagulants.
- Serotonin Syndrome: Concomitant use of drugs that increase serotonin synthesis, block serotonin reuptake, and/or impair serotonin metabolism (e.g., monoamine oxidase inhibitors [MAOIs]). Of note, concomitant use of some serotonergic agents, such as MAOIs, is contraindicated.
- Discontinuation: Avoid abrupt discontinuation; taper dose gradually. If intolerable symptoms, resume previous dose followed by smaller decreases
- Acute recovery period after myocardial infarction.
- Click Elavil® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- Antidepressants: Risk of serotonin syndrome (symptoms include fever, altered mental status, rigidity) if combined with drugs that alter serotonin synthesis, metabolism, or degradation such as monoamine oxidase inhibitors (MAOIs) & other antidepressants (selective serotonin reuptake inhibitors [SSRIs] and serotonin norepinephrine reuptake inhibitors [SNRIs]), etc.
- Triptans: Triptans have been listed as a risk for serotonin syndrome (symptoms include fever, altered mental status, rigidity) alone or when combined with certain antidepressants that alter serotonin synthesis, metabolism, or degradation. The American Headache Society however issued a position statement that there was insufficient evidence to link triptans with serotonin syndrome whether used as monotherapy or when combined with other serotonergic medications. Headache specialists commonly prescribe triptans and antidepressants together.
- CYP2D6 inhibitors: Drugs that inhibit CYP2D6 may increase serum levels of this medication. Strong inhibitors include bupropion, dacomitinib, fluoxetine, paroxetine, quinidine and tipranavir.
- Drugs that increase the QT interval: Caution should be used when combining amitriptyline with other drugs that increase the QT interval.
- Amphetamines: Use of these medications with amitriptyline may increase the risk of serotonin syndrome
- Ondansetron: Use of this medication with amitriptyline may increase the risk of serotonin syndrome; however, risk for serotonin syndrome is low with concomitant use of these medications.
- Buspirone: Use of this medication with amitriptyline may increase the risk of serotonin syndrome
- Fentanyl: Use of this medication with amitriptyline may increase the risk of serotonin syndrome
- Anticoagulants: Use of these medications with amitriptyline may increase the risk of bleeding
- Ergots: Use of this medication with amitriptyline may increase the risk of serotonin syndrome; this does not contraindicate use but monitor for signs or symptoms of serotonin syndrome.
- Dextromethorphan: Use of this medication with amitriptyline may increase the risk of serotonin syndrome
- Consider starting a preventive therapy in those with 4 or more migraine days per month.
- Have the patients keep a headache diary to assess the frequency of migraine days per month. This will also help in assessing the response of the preventive medication.
- Counsel patients that it may take 1-4 months after the start of an oral preventive to see an adequate response.
- Set realistic goals with your patients. Tell them that a preventive medication is not a cure for migraines. A good response would be a 50% or more reduction in the frequency of migraine days per month.
- Counsel patients on side effects or they may discontinue the medication.
- Offer a 3-4 month trial of this medication to access efficacy.
- If a patient experiences somnolence in the morning as a side effect to this medication, then have them administer it earlier in the evening (e.g., 2-3 hours prior to bedtime as opposed to at bedtime, which is normally done).
NORTRIPTYLINE Not FDA Approved for Migraine Prevention (Pamelor®) CLICK HERE TO EXPAND or Contract
Brands: Dosages Available:
Headache Specialist Suggestions:
Precautions and Risks:
Contraindications:
Pregnancy & Breast Feeding:
Important Drug Interactions:
Counseling Tips:
- 10, 25, 50 and 75 mg capsules
- 10 mg by mouth at bedtime
- 10-150 mg by mouth once daily at bedtime
- Some experts suggest that a lower maintenance dose range of 20 -50 mg once daily at bedtime due to tolerability
- First office visit:
- 10 mg by mouth at bedtime
- Increase to 20 mg by mouth at bedtime at 2 weeks if not having intolerable side effects
- Tell the patient that if they cannot tolerate a particular dose then reduce it to the previous dosage that they could tolerate
- Second office visit (2 months after first visit):
- if satisfactory response (>50% decrease in the frequency of migraine days per month as compared to baseline) then continue 20 mg dose.
- If no satisfactory response, increase dose to 30 mg by mouth at bedtime for 2 weeks and then 40 mg by mouth at bedtime if possible.
- Tell the patient that if they cannot tolerate a particular dose then reduce it to the previous dosage that they could tolerate
- Dry mouth, dry eyes and sedation are the most common
- Less common: constipation, upset stomach, sedation, and blurred vision
- Weight gain possible, but less likely with the lower dosages used for migraine prevention. Nevertheless, still need to monitor for weight gain.
Headache Specialist Suggestions:
- Considered one of “first line” preventives, a group of medications that are commonly recommended as initial therapy in those starting a preventive for the first time.
- Beta blockers and topiramate are also considered “first line” preventives.
- Might use in the following patients:
- Those that are very sensitive to medication side effects as it has a lower incidence of side effects.
- Those who have attacks of tension headache. Amitriptyline is a first line therapy for prevention of tension headaches.
- Those with other pain disorders such as fibromyalgia, low back pain, occipital neuralgia and others since nortriptyline might decrease the pain severity of those conditions as well.
- When considering a tricyclic antidepressant, usually choose between amitriptyline and nortriptyline.
- Consider using amitriptyline if they have insomnia and nortriptyline if they do not have insomnia.
- If patients are very sensitive to medication side effects, nortriptyline tends to have fewer side effects than amitriptyline.
- Main advantages of nortriptyline are:
- Good efficacy, long track record of safety and low cost.
- Main disadvantages are:
- Side effect of weight gain (although less with lower dosages) and sedation, which can cause some patients to not want to take this medication.
- Avoid use in those with QT prolongation.
- Some headache experts will get an EKG on all patients prior to start of nortriptyline to rule out QT prolongation.
- Others would get an EKG only in those at high risk for QT prolongation, which include patient with any of the following: 1) older age (e.g., ≥ 65 years of age), 2) past cardiac disease and 3) those receiving multiple medications that prolong the QT interval.
- Might also consider an EKG to rule out QT prolongation when higher dosages of nortriptyline are given (e.g., 50 mgs or greater).
- Often need to combine nortriptyline with another preventive to see optimal response in those with more frequent attacks of migraine.
Precautions and Risks:
- QT prolongation: QT prolongation particularly with higher dosages or if combined with other medications that prolong the QT interval. May need to obtain an EKG at baseline in those at risk for having QT prolongation. Avoid medication in those with QT prolongation
- Suicidal thoughts: Antidepressants have been associated with suicidal thoughts and behavior if used in adolescents and young adults
- Comorbid illnesses: Cautious use in the elderly as well as those with cardiovascular disease, urinary retention, bipolar disease, constipation and hepatic or renal disease.
- Pregnancy and Lactation: Consult package insert
- Bleeding risk: May increase the risk of bleeding if combined with antiplatelet meds or anticoagulants.
- Serotonin Syndrome: Concomitant use of drugs that increase serotonin synthesis, block serotonin reuptake, and/or impair serotonin metabolism (e.g., monoamine oxidase inhibitors [MAOIs]). Of note, concomitant use of some serotonergic agents, such as MAOIs, is contraindicated.
- Discontinuation: Avoid abrupt discontinuation; taper dose gradually. If intolerable symptoms, resume previous dose followed by smaller decreases
Contraindications:
- Acute recovery period after myocardial infarction.
Pregnancy & Breast Feeding:
- Click Pamelor® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
Important Drug Interactions:
- Antidepressants: Risk of serotonin syndrome (symptoms include fever, altered mental status, rigidity) if combined with drugs that alter serotonin synthesis, metabolism, or degradation such as monoamine oxidase inhibitors (MAOIs) & other antidepressants (selective serotonin reuptake inhibitors [SSRIs] and serotonin norepinephrine reuptake inhibitors [SNRIs]), etc.
- Triptans: Triptans have been listed as a risk for serotonin syndrome (symptoms include fever, altered mental status, rigidity) alone or when combined with certain antidepressants that alter serotonin synthesis, metabolism, or degradation. The American Headache Society however issued a position statement that there was insufficient evidence to link triptans with serotonin syndrome whether used as monotherapy or when combined with other serotonergic medications. Headache specialists commonly prescribe triptans and antidepressants together.
- CYP2D6 inhibitors: Drugs that inhibit CYP2D6 may increase serum levels of this medication. Strong inhibitors include bupropion, dacomitinib, fluoxetine, paroxetine, quinidine and tipranavir.
- Drugs that increase the QT interval: Caution should be used when combining amitriptyline with other drugs that increase the QT interval.
- Amphetamines: Use of these medications with amitriptyline may increase the risk of serotonin syndrome
- Ondansetron: Use of this medication with amitriptyline may increase the risk of serotonin syndrome; however, risk for serotonin syndrome is low with concomitant use of these medications.
- Buspirone: Use of this medication with amitriptyline may increase the risk of serotonin syndrome
- Fentanyl: Use of this medication with amitriptyline may increase the risk of serotonin syndrome
- Anticoagulants: Use of these medications with amitriptyline may increase the risk of bleeding
- Ergots: Use of this medication with amitriptyline may increase the risk of serotonin syndrome; this does not contraindicate use but monitor for signs or symptoms of serotonin syndrome.
- Dextromethorphan: Use of this medication with amitriptyline may increase the risk of serotonin syndrome
Counseling Tips:
- Consider starting a preventive therapy in those with 4 or more migraine days per month.
- Have the patients keep a headache diary to assess the frequency of migraine days per month. This will also help in assessing the response of the preventive medication.
- Counsel patients that it may take 1-4 months after the start of an oral preventive to see an adequate response.
- Set realistic goals with your patients. Tell them that a preventive medication is not a cure for migraines. A good response would be a 50% or more reduction in the frequency of migraine days per month.
- Counsel patients on side effects or they may discontinue the medication.
- If your patients experience somnolence in the morning as a side effect to this medication then have them administer it earlier in the evening (e.g., 2-3 hours prior to bedtime as opposed to at bedtime, which is normally done).
SNRIs
VENLAFAXINE NOT FDA APPROVED FOR MIGRAINE PREVENTION (EFFEXOR®) CLICK HERE TO EXPAND OR CONTRACT
Brands:Available Dosages:
Precautions and Risks:
Contraindications:
Pregnancy & Breast Feeding:
Drug interactions:
Counseling Tips:
- 37.5, 75 and 150 mg capsules
- 37.5 mg by mouth daily, taken in am
- 75-150 mg by mouth daily
- First office visit:
- 37.5 mg by mouth once daily for 3 days, then increase the dosage to 75 mg once daily if tolerated.
- Second office visit (2 months later):
- If the patient has a satisfactory response (e.g., defined as a 50% decrease in the frequency of migraine days per month), continue current dosage
- If unsatisfactory response, increase to 150 mg by mouth daily.
- May split dose to 75mg in am and 75mg at noon, to minimize side effects
- Agitation, alertness, insomnia, in some, patients, drowsiness, dizziness, weakness, nausea, diaphoresis, weight loss, xerostomia, less often, sexual dysfunction
- Can increase blood pressure
- Can be used if “first line” preventives have not been effective.
- Tricyclic antidepressants, beta blockers and topiramate are also considered “first line” preventives.
- It is hypothesized that it is necessary to block reuptake of both serotonin and norepinephrine to achieve a preventive response.
- Therefore, selective serotonin reuptake inhibitors generally are not considered effective preventive medications for migraine.
- SNRIs might be particularly useful in the following patients:
- Those with depression or generalized anxiety disorder and frequent migraine (e.g., ≥ 4 days per month with migraine)
- Those that do not tolerate the side effects of the tricyclic antidepressants
- Women with a worsening frequency of migraine, dysthymia or hot flashes during the perimenopause or early menopausal time periods.
- SNRIs may treat the migraine as well as the menopausal symptoms.
- Main advantages are:
- Good efficacy and relatively low side effect profile.
- Main disadvantages are:
- Caution patients that they may develop withdrawal symptoms (e.g., dizziness, anxiety, irritability, etc.) if rapidly discontinuing this medication. Thus, slow weaning of venlafaxine is recommended when stopping the medication.
Precautions and Risks:
- Suicidal thoughts: Antidepressants have been associated with suicidal thoughts and behavior if used in adolescents and young adults.
- Increased blood pressure: Elevations in blood pressure have been encountered with venlafaxine particularly at higher dosages.
- Bleeding risk: May increase the risk of bleeding if combined with antiplatelet meds or anticoagulants.
- Pregnancy and Lactation: Consult package insert.
- Comorbid illnesses: Cautious use in those with bipolar disease and hepatic or renal disease.
- Hepatotoxicity: Venlafaxine has rarely been associated with drug induced liver disease.
- CNS Depression: Venlafaxine may cause CNS depression which can impair mental abilities, patients must be cautioned about performing tasks that require mental alertness (driving or operating machinery)
Contraindications:
- Concomitant use of MAOIs (including linezolid or IV methylene blue). Do not use an MAOI within 7 days of venlafaxine discontinuation or begin venlafaxine within 14 days of discontinuing an MAOI.
Pregnancy & Breast Feeding:
- Click Effexor®XR and navigate to #8 Use in Specific Populations (8.1 & 8.2)
Drug interactions:
- Triptans: Concomitant use has been listed as a risk for serotonin syndrome (symptoms include fever, hypertension, altered mental status, rigidity) if combined with certain antidepressants that alter serotonin synthesis, metabolism, or degradation. The American Headache however issued a position statement that there was insufficient evidence to link triptans with serotonin syndrome whether used as monotherapy or when combined with other serotonergic medications. Headache specialists commonly prescribe triptans and antidepressants together.
- Amphetamines: Use of these medications with venlafaxine may increase the risk of serotonin syndrome.
- Ondansetron: Use of this medication with venlafaxine may increase the risk of serotonin syndrome; however, risk for serotonin syndrome is low with concomitant use of these medications.
- Buspirone: Use of this medication with venlafaxine may increase the risk of serotonin syndrome.
- Fentanyl: Use of this medication with venlafaxine may increase the risk of serotonin syndrome.
- Anticoagulants: Use of these medications with venlafaxine may increase the risk of bleeding.
- Monoamine oxidase inhibitors: See above contraindications.
- Ergots: Use of this medication with venlafaxine may increase the risk of serotonin syndrome; this does not contraindicate use but monitor for signs or symptoms of serotonin syndrome.
- Dextromethorphan: Use of this medication with venlafaxine may increase the risk of serotonin syndrome.
- Lasmiditan: Use of this medication with venlafaxine may increase the risk of serotonin syndrome.
- Nonsteroidal Anti-inflammatory Medications: May increase the antiplatelet effects of venlafaxine and increase bleeding risk.
- Tramadol: Use of this medication with venlafaxine may increase the risk of serotonin syndrome
- Trazodone: May enhance the serotonergic effect of Serotonin/Norepinephrine Reuptake Inhibitors and increase the risk of serotonin syndrome.
- Tricyclic Antidepressants: Serotonin/Norepinephrine Reuptake Inhibitors may enhance serotonergic effect of tricyclic antidepressants which can result in serotonin syndrome.
- Midodrine: May enhance the sympathomimetic effects (e.g., tachycardia)
Counseling Tips:
- Consider starting a preventive therapy in those with 4 or more migraine days per month.
- Have the patients keep a headache diary to assess the frequency of migraine days per month. This will also help in assessing the response of the preventive medication.
- Counsel patients that it may take 1-4 months after the start of an oral preventive to see an adequate response.
- Set realistic goals with your patients. Tell them that a preventive medication is not a cure for migraines. A good response would be a 50% or more reduction in the frequency of migraine days per month.
- Counsel patients on side effects or they may discontinue the medication.
- Take this medication with food at the same time of the day (morning).
- Tell your patients not to discontinue this medication without consulting their provider as they may experience withdrawal symptoms (e.g., anxiety, dizziness, irritability, etc.).
DULOXETINE NOT FDA APPROVED FOR MIGRAINE PREVENTION (CYMBALTA®, IRENKA®) CLICK HERE TO EXPAND OR CONTRACT
Brands:
Common Side Effects:
Precautions and Risks:
Pregnancy & Breast Feeding:
Click Cymbalta® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
Click Irenka® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
Important Drug Interactions:
Counseling Tips:
- Cymbalta® DR (duloxetine) For Complete Prescribing Information Click Here for the Package Insert
- Irenka® DR (duloxetine) For Complete Prescribing Information Click Here for the Package Insert
- 20, 30 and 60 mg capsules
- 30 mg by mouth once daily is the most common initial dosage
- 20 mg by mouth once daily might be used in those with medication intolerances
- 30-60 mg by mouth once daily
- May go up as high as 120 mg once daily or 60 mgs twice daily in some patients.
- Office visit 1:
- 30 mg by mouth once daily
- Office visit 2 (2 months later):
- If a satisfactory response (e.g., defined as a 50% decrease in the frequency of migraine days per month) then continue current dosage
- If unsatisfactory response, increase to 60 mg by mouth once daily if tolerating lower dosage.
Common Side Effects:
- weight loss, abdominal pain, decreased appetite, nausea, xerostomia, lethargy, fatigue, sexual dysfunction, and headache
- Rarely can occasionally see elevations in blood pressure with this medication
- Can be used if “first line” preventives have not been effective.
- Tricyclic antidepressants, beta blockers and topiramate are also considered “first line” preventives.
- It is hypothesized that it is necessary to block reuptake of both serotonin and norepinephrine to achieve a preventive response.
- Therefore, selective serotonin reuptake inhibitors generally are not considered effective preventive medications for migraine.
- SNRIs may be a good choice in the following groups of patients:
- Those with depression or generalized anxiety disorder and frequent migraine (e.g., ≥ 4 days per month with migraine)
- Those who have side effects to the tricyclic antidepressants.
- Those with coexisting pain (from other conditions) or depression may be particularly good candidates, as duloxetine been FDA approved for treatment of both fibromyalgia and major depression
- Main advantages are:
- Good efficacy and relatively low side effect profile
- Main disadvantages are:
- Some patients will develop withdrawal symptoms (e.g., dizziness, anxiety, irritability, etc.) when stopping the medication. For this reason, a slow wean of the medication is recommended when stopping the medication.
- Dizziness and lightheadedness, particularly in older patients
Precautions and Risks:
- Suicidal thoughts: Antidepressants have been associated with suicidal thoughts and behavior if used in adolescents and young adults.
- Increased blood pressure: Elevations in blood pressure have been encountered with duloxetine.
- Bleeding risk: May increase the risk of bleeding if combined with antiplatelet meds or anticoagulants.
- Pregnancy and Lactation: Consult package insert
- Comorbid illnesses: Cautious use in those with bipolar disease and hepatic or renal disease.
- Hepatotoxicity: Duloxetine has rarely been associated with drug induced liver disease.
- Use with caution or avoid as potentially inappropriate in older patients
- Do not use MAOIs within 7 days of venlafaxine discontinuation or use venlafaxine within 14 days of discontinuing an MAOI.
Pregnancy & Breast Feeding:
Click Cymbalta® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
Click Irenka® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
Important Drug Interactions:
- Triptans: Have been listed as a risk for serotonin syndrome (symptoms include fever, hypertension, altered mental status, rigidity) if combined with certain antidepressants that alter serotonin synthesis, metabolism or degradation. The American Headache however issued a position statement that there was insufficient evidence to link triptans with serotonin syndrome whether used as monotherapy or when combined with other serotonergic medications. Headache specialists commonly prescribe triptans and antidepressants together.
- Amphetamines: Use of these medications with duloxetine may increase the risk of serotonin syndrome.
- Ondansetron: Use of this medication with duloxetine may increase the risk of serotonin syndrome; however, risk for serotonin syndrome is low with concomitant use of these medications.
- Metoclopramide: May result in an increased risk of extrapyramidal reactions and neuroleptic malignant syndrome.
- Buspirone: Use of this medication with duloxetine may increase the risk of serotonin syndrome.
- Fentanyl: Use of this medication with duloxetine may increase the risk of serotonin syndrome.
- Anticoagulants: Use of these medications with duloxetine may increase the risk of bleeding.
- Monoamine oxidase inhibitors: Use of this medication with duloxetine may increase the risk of serotonin syndrome; Avoid this medication.
- Ergots: Use of this medication with duloxetine may increase the risk of serotonin syndrome; this does not contraindicate use but monitor for signs or symptoms of serotonin syndrome.
- Dextromethorphan: Use of this medication with duloxetine may increase the risk of serotonin syndrome.
- Lasmiditan: Use of this medication with duloxetine may increase the risk of serotonin syndrome.
- Nonsteroidal Anti-inflammatory Medications: May increase the antiplatelet effects of duloxetine and increase bleeding risk.
- Tramadol: Use of this medication with duloxetine may increase the risk of serotonin syndrome.
- Midodrine: May enhance the sympathomimetic effects (e.g., tachycardia) if combined with this medication.
- CYP2D6 inhibitors: Drugs that inhibit CYP2D6 may increase serum levels of this medication. Strong inhibitors include bupropion, dacomitinib, fluoxetine, paroxetine, quinidine and tipranavir.
Counseling Tips:
- Consider starting a preventive therapy in those with 4 or more migraine days per month.
- Have the patients keep a headache diary to assess the frequency of migraine days per month. This will also help in assessing the response of the preventive medication.
- Counsel patients that it may take 1-4 months after the start of an oral preventive to see an adequate response.
- Set realistic goals with your patients. Tell them that a preventive medication is not a cure for migraines. A good response would be a 50% or more reduction in the frequency of migraine days per month.
- Counsel patients on side effects or they may discontinue the medication.
- Counsel patient or caregiver to report worsening depression, suicidal ideation, or unusual changes in behavior.
- Advise patients against sudden discontinuation to prevent withdrawal symptoms.