A 45 year-old woman is treated with citalopram since two months/n(30 mg per day). Due to migraine s

Fråga: A 45 year-old woman is treated with citalopram since two months

(30 mg per day). Due to migraine she is using sumatriptan 0 to 3 times per month. Is the combination inappropriate?

Sammanfattning: There is a theoretical risk of an interaction between SSRI and sumatriptan. There are two case reports with adverse effects when sumatriptan and SSRIs were combined, although with an unclear cause effect relationship. However, 14 patients receiving different antidepressants (13 on SSRIs) did not experience significant side effects when they took oral sumatriptan for the relief of migraine. If patients are treated with sumatriptan and a SSRI, a follow-up of the patients is needed.

Svar: The question has been answered previously in Drugline (1,2 enclosed). Since serotonin levels can be increased during treatment with sumatriptan, there is a theoretical risk of interaction in combination with selective serotonin reuptake inhibitors (SSRIs). According to the manufacturer a paper has been published concerning two case reports in patients treated with SSRIs and sumatriptan (3). In one patient treated with the combination of methysergine, lithium, and sertraline (unknown doses) sumatriptan was added due to migraine. One hour after a 6 mg subcutaneous dose of sumatriptan, the patient was brought to the emergency room with a sudden onset of weakness, severe incoordination, and abnormal jerking movements. The symptoms resolved within 24h, except for hyperreflexia which persisted for two days. Once sertraline was discontinued, sumatriptan was an effective migraine remedy without adverse side effects (3). In the second case the patient was treated with sertraline 100 mg daily. Ten minutes after an subcutaneous injection of sumatriptan the patient became anxious, agitated, disoriented and diffusely weak. Improvement began within 3h of the symptoms onset, and after 24h there was no neurological deficit. The sertraline was discontinued. The patient experienced no similar events when sumatriptan was combined with nortriptyline (3). Due to these published case reports the text in FASS (the Swedish Catalogue of Approved Medical Products) for the nasal spray of sumatriptan was changed and þIf patients are treated with sumatriptan and a SSRI is indicated, a follow-up of the patient is neededþ was added. In the text it is mentioned that there are two case reports concerning patients who developed a feeling of weakness, hyperreflexia and incoordination on sumatriptan and SSRIs.

However, in a published article 14 patients on different antidepressant drugs did not experience significant side effects when they took oral sumatriptan (4).

An updated search on Medline and SADRAC (Swedish Drug Adverse Reaction Advisory Committee) has not revealed any new information about any interactions between SSRIs and sumatriptan. 1 Drugline nr 11842 (year 1995) (enclosed) 2 Drugline nr 11932 (year 1995) (enclosed) 3 Mathew NT, Tietjen GE, Lucker C: Serotonin syndrome complicating migraine pharmacotherapy. Cephalgia 1996; 16: 323-227 (enclosed) 4 Blier P, Bergeron R: The safety of concomitant use of sumatriptan and antidepressant treatment. J Clin Psychopharmacol 1995; 15: 106-109 (enclosed)