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Mixing Some Antidepressants and Migraine Drugs May Cause Lethal Serotonin Syndrome

with 47 comments

U.S. Food and Drug Administration (FDA) published a warning that mixing certain sSRI/SNRI-type of antidepressant medications and triptan-based migraine drugs may cause a potentially lethal condition called Serotonin Syndrome.

According to the FDA website, when the body has too much serotonin, symptoms of Serotonin Syndrome will occur. These symptoms may include restlessness, hallucinations, loss of coordination, fast heart beat, rapid changes in blood pressure, increased body temperature, overactive reflexes, nausea, vomiting, and diarrhea. Usually symptoms happen when the drug dose is increased or when the patient is started on the drug.

The FDA website listed some commonly prescribed drugs within the classes at risk:

SSRIs and a Combination Drug Containing an SSRI
* Celexa (citalopram)
* Fluvoxamine
* Lexapro (escitalopram)
* Paxil (paroxetine)
* Prozac (fluoxetine)
* Symbyax (olanzapine/fluoxetine)
* Zoloft (sertraline)

SNRIs
* Cymbalta (duloxetine)
* Effexor (venlafaxine)

Triptans
* Amerge (naratriptan)
* Axert (almotriptan)
* Frova (frovatriptan)
* Imitrex (sumatriptan)
* Maxalt and Maxalt-MLT (rizatriptan)
* Relpax (eletriptan
* Zomig and Zomig ZMT(zolmitriptan)

Written by Jane Chin, Ph.D.

Posted in Mental Health

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47 Responses to 'Mixing Some Antidepressants and Migraine Drugs May Cause Lethal Serotonin Syndrome'

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  1. Good Afternoon,

    My name is C. and I have been ’somewhat’ diagnosed with Bipolar disorder, however my Doctor does not want to say yes or no due to potential error (miss-diagnosis). She has given me a prescription of Seroquel, which I had taken before, but this time she suggests I take it at my high points, but what about my low points. The reckless euphoria can be beat, but the hopelessness I feel like I can’t go on. Do you have any suggestions? Should I be on another Med. for my down time? I was on Celexa and Seroquel at the same time before but I had many suicide attempts. I just want to feel normal. Thanks for your time. Hope to hear from you soon. Take Care! C.

    C

    23 Jan 07 at 7:59 am

  2. Dear C,

    I can understand your concern for your “low points.”

    You may want to seek a second opinion with a psychiatrist who specializes in treating bipolar disorder. I’m not sure if the doctor you are visiting is your family doctor or a specialist.

    I encourage you to call your insurance carrier’s mental health division and ask for a referral to a specialist in the BP area.

    Best wishes,
    Jane

    Jane Chin, Ph.D.

    24 Jan 07 at 4:46 pm

  3. Thank you very much much Dr.Chin. I appreciate the feed back and have talked to my psychiatrist and counsellors and they have put on Celexa once again, and am feeling much better. Take Care :)

    C.

    C.

    8 Feb 07 at 9:01 am

  4. is it ok to mix citalopram with effexor?the dr is slowly taken my husband off effexor to start him on citalopram he went from 300 mgs to 150 to 75 now hes on 35mgs then after that iam to start him on the citalopram 20mgs, but hes depression is there i was wondering if it would be ok if i started the citalopram she also has him on 4mgs f risperidone,maybe iam losing my mind but afetr all these years iam looking for a wonder drug!

    jackie

    1 May 07 at 7:52 am

  5. Jackie,

    I’d follow your husband’s doctor’s instructions EXACTLY as given and not change anything. If you are noticing side effects or concerns with your husband, you would want to notify his doctor immediately and ask what, if anything, may be done.

    Best wishes,
    Jane Chin

    Jane Chin, Ph.D.

    1 May 07 at 8:11 am

  6. Is it okay to mix citalopram and and acetaminophen? I take 40mg of Celexa every day, and was never told if taking 1000mg of acetaminophen would alright, or if that would cause some kind of reaction.

    Leda

    27 May 07 at 3:47 pm

  7. Leda,

    I’d ask your psychiatrist that question. Here’s some additional information that may be useful:

    My understanding is that both drugs are metabolized in the liver through the cytochrome P450 enzyme system, although acetaminophen is only metabolized 5% in the liver, and when acetaminophen is mixed with alcohol, this becomes a potentially harmful 5%. If the same enzymes process both drugs, then the drug levels of one or both drugs may be different in the blood when compared to taking either citalopram alone or acetaminophen alone.

    P450 CYP3A4 and CYP2C19 enzymes metabolize citalopram. Based on this link, acetaminophen is metabolized by P450 CYP2E1, so it appears that the drugs go through different enzymes in the liver.

    Most of the caution I’ve found re: acetaminophen and citalopram involve formulations of narcotic drugs that include acetaminophen, but not acetaminophen alone. For example:

    Citalopram Interactions (scroll down)

    Best wishes,
    Jane

    Jane Chin, Ph.D.

    31 May 07 at 12:30 pm

  8. has mixing wellbutrin sr and seroquel ever worked for anyone ?

    amy

    2 Jun 07 at 7:07 pm

  9. What are the risks of mixing Paxil and Sandoz with weed. My husband is on both medication and I think he has started smoking pot.

    Rachel

    5 Aug 07 at 1:15 pm

  10. Rachel,

    As a general rule, mixing any medications without the doctor’s oversight is a very bad idea, and mixing any medications with weed is both a very bad idea and a potentially dangerous idea. It may be time to have an honest talk with your husband about this because he may be putting himself at medical risk without realizing it.

    Jane

    Jane Chin, Ph.D.

    6 Aug 07 at 7:56 pm

  11. Can you take Axert if you are currently taking 10mg of Lexapro a day? What can you take if you have a headache? Is Tylenol okay?

    Jessica

    24 Sep 07 at 11:31 am

  12. I take very low dose of celexa is it okay to take maxalt for an occasional miagraine

    carole

    5 Feb 08 at 3:50 pm

  13. hi i was just wondering if mixing celexa and relpax is okay?

    sheila

    24 Mar 08 at 11:27 pm

  14. Hi Jessica, Carole, and Sheila -

    For these types of questions you definitely need to ask your doctor. You want to be careful mixing any medications (prescription or otherwise) whether one or both is/are “low dose” or regular dose.

    Sheila, since Celexa and Relpax are both listed above in the post relating to the serotonin syndrome risk, you will need to check with your psychiatrist regarding the pharmacology of the drugs and whether the dosages you’re taking (I assume you are taking both) are within what your doctor believes to be acceptable.

    Jane

    Jane Chin, Ph.D.

    25 Mar 08 at 6:14 pm

  15. hi can i mix celexa and cymbalta together… i liked celexa, however, hated the hunger and cymbalta makes me less patience…

    danielle

    11 Apr 08 at 6:24 am

  16. Hey there. Ive had ongoing problems with doctors, to the point of gettin very frustrated. I went in there with a problem in my stomach and anxiety… I came out with antidepressants, which I was very cautious about because I know myself I have never been depressed or really down. They gave me Venlafaxine, started it on 75 Mg’s. I got every single side effect, and bad. then they changed it, to Citalopram, 20 mg’s. and it made me feel WIRED and high on drugs like you wouldnt believe. Now, I used to get a slight halucination, and almost everything it says about “Seretonin Syndrome”.. which makes me wonder, why would the doctors give me all these pills for nothing? And what can happen when taking Venlafaxine, Metoclop, Ativan lorazepam, then changed to Citalopram, Clonazepam and Pariet? It seems like ALOT of pills to be prescribed just for a small anxiety problem, and problems with my stomach ( which is now diagnosed as Gastro-esophageal Reflux Disease ) I just want to be back to normal, and they wont help me. What should I do?? They are sending me for CT scans now, and Ive just been getting aggravated with there “help” as they like to call it.

    Colt

    20 Jun 08 at 1:26 pm

  17. @ Colt:

    Dear Colt, I’m sorry to hear about your experience with doctors. I’m not sure if you’ve been going to primary care physicians (sometimes also called general practitioners), but for your situation I’m surprised that you were not referred out immediately to a specialist. That said, you may want to call your insurance company and explain the situation, and perhaps point out that from their perspective, misdiagnosing you can be extremely expensive for the insurance companies given that the doctors submit bills and get reimbursed for part of their services. In addition, you now have new side effects that you didn’t have before, that requires managing, and this obviously creates additional liabilities to the insurance companies…..

    It may be time to change doctors and find one who is willing to listen to you, who doesn’t act like he or she knows everything within a 5 minute period then immediately sends you out the door with a prescription, and one who is conscientious enough to know when the scope of your symptoms is beyond his / her expertise and requires a specialist’s attention.

    Best of luck and please keep me posted,
    Jane

    Jane Chin, Ph.D.

    20 Jun 08 at 5:22 pm

  18. I was diagnosed with bi-polar disorder in March. I am on Symbyax 3/25mg. It works, but my highs and lows dont come as fast as they use to. My question is can my body become resistant to Symbyax? I feel like it is not working as much anymore, and I am concerned. Suicide is not an answer, but it sometimes seems like the best choice. No more conflict within myself.

    Thanks,
    Ericka

    Ericka

    13 Aug 08 at 6:20 pm

  19. Hi Ericka,

    Symbyax is a combination of active ingredients in Zyprexa and Prozac. I’m not familiar with how the body can respond over time to Zyprexa, but given that Prozac is a SSRI, there may be potential for reduced response (sometimes called “serotonin poop out”).

    However, whether your body is really becoming resistant can only be determined by your physicians. If you suspect that you aren’t getting the relief you once expected, you will need to make an appointment with your doctor to see what is happening.

    I agree with you, suicide is not an answer. What you’re going through feels tough, but you are tougher.

    Best wishes to you,
    Jane

    Jane Chin, Ph.D.

    21 Aug 08 at 5:53 am

  20. My question is plain and simply, is there any medicine I can take for headaches/minor aches and pains, while taking my prescribed Celexa?

    Thanks,
    Jill

    Jill

    7 Sep 08 at 3:31 pm

  21. My question is about mixing the antidepressant Cipralex (known as Lexapro(escitalopram))in the states with cannabis.

    I’m on ten miligram pills and have only been on it for just over one week with no real adverse side effects. When I smoked cannabis a few days ago it gave me a scary high that came with paranoia, shaking, hot and then coldness in temperature, and vomitting.

    I’m just wondering if you can explain why that might have happened to me?

    Sarah

    28 Dec 08 at 3:40 pm

  22. Dear Sarah,

    I would recommend that you immediately stop smoking cannabis, as like other drugs, mixing cannabis with antidepressants may lead to side effects that can be serious (and scary, as you personally have experienced).

    I’d ask that you tell your doctor about what has happened, because the side effects you experienced are pretty serious and you should be monitored to make sure that your body’s OK.

    Best wishes,
    jane

    Jane Chin, Ph.D.

    30 Dec 08 at 11:01 am

  23. Can i take citalopram with acetaminophen or ibrofen?

    Tylenol PM?

    Rella

    4 Jan 09 at 11:11 am

  24. my daughter recently went into an in-patient treatment center. she has been dealing with depression and anxiety she has a hard time eating sleeping and a history of self-harm. they called today and want to put her on 20mg of celexa and 25mg of seroqual. i know the are low doses but i am worried about the suicidal attempts i have read about. is it a good idea to combine the two?

    joy

    12 Jan 09 at 6:54 pm

  25. hello I was just wondering if it was ok that my wife has been prescribed paroxetine (20mg two tabets daily) sertraline (50 mg 2 tablets daily) clonazepan (.5 mg 4x a day) is all this safe or necassary? She does not take them regularly and she sometimes drinks with them. She seems fine sometimes but wants to sleep all the time and does not do much else when she is awake except to go to work. Can I talk to her docter because I don’t think she is telling him the truth. Plus when will she be taken off these drugs or is she doomed to take them for the rest of her life? They are habbit forming and it is not something I want to live with for the rest of my life plus we have two kids. Any suggestions?

    Thank You,

    K. Ross

    k. ross

    13 Jan 09 at 2:07 pm

  26. I am currently taking 200 mg of seroguil at night along with 100 mg of topamax for bipolar and in the am I take 60 mg of prozac and 300 mg of wellbutrin xl. Where can I look to find like a combined affect of all these drugs on the body? I want to be able to type in a formula of these and come up with how they interact and possible side effects with them together.

    beth

    15 Jan 09 at 9:44 am

  27. A fam. member is currently in a psych ward at a hospital. I asked her what drugs they have her on, and she said She is currently taking effexor, prozac, neurontin, trazadone, and fasaclo.. Is the combination dangerous? If so, how? Causes? Please email me!

    Katelyn

    28 Jan 09 at 9:25 pm

  28. Hi Katelyn, I’m sorry to hear about your family member. Usually when a person has to be hospitalized, the mental condition is quite serious, and therefore, an intensive treatment approach is used. This can involve multiple medications given at the same time. I’d recommend that you ask the psychiatrist who is responsible for your family member your question on the combination of these drugs, and what kind of side effects there may be (drug-drug interactions). Best wishes to you, Jane.

    Jane Chin, Ph.D.

    3 Feb 09 at 9:21 pm

  29. Dear Beth, you may want to look at the “prescribing information” or “package insert” that should be available either from the drug’s website (especially if the drug is not yet generic) or from reliable internet websites on drug information. Look at sections called “contraindications” and sections on drug interactions. The information may look intimidating at first because off all the fine print, but there is often a patient information section that tries to put into plain english what it all means to you as a patient. I’m not aware of a website that lets you type in a list and come up with drug-drug interaction potential – it’s a great idea for a website, though! Jane.

    Jane Chin, Ph.D.

    3 Feb 09 at 9:28 pm

  30. Dear Mr. Ross, no matter what drug she may be prescribed, DRINKING IS NOT OK with any meds – and it can be particularly dangerous with the clonazepan. It is not uncommon for a doctor to prescribe 2 types of antidepressants if the doctor decides that the patient can best benefit from the combination, although I would ask the doctor questions if I have questions. Sleepiness (somnolence) is a common side effect in some antidepressants, and certainly the clonazepan will make most people sleepy. I’d have that conversation with her doctor if you have concerns – it’s the doctor’s obligation to make sure that the patient is monitored very carefully, and especially if you know that she drinks sometimes, the doctor needs to know about it. Best wishes to you, Jane.

    Jane Chin, Ph.D.

    3 Feb 09 at 9:32 pm

  31. Dear Joy, I’d recommend that you bring up your concern with the combination to the doctor treating your daughter; I assume that the doctor is aware of your daughter’s history of self harm. The doctor should monitor your daughter’s response on the drug combination very diligently and make sure that the treatment is working in the right direction. You may also want to be alert to changes in your daughter’s behavior, and report any changes that you are worried about to your daughter’s doctor. Thank you for being a caring mom. My best wishes to you, Jane.

    Jane Chin, Ph.D.

    3 Feb 09 at 9:36 pm

  32. I got out of drug rehab in January and cannot get a grip on my emotionc. I am not depressed but severly agiatated. It is starting to affect my family. My doctor put me on Paxil(20mg) and I saw no improvement so she switched me to Lexapro(10mg). I am desperate because I feel myself being alienated from my family and I love them dearly and have already put them through enough with the drug rehab(9weeks). Thank you

    donna peavy

    10 Mar 09 at 4:38 am

  33. I was recently prescribed 10mg of fluoextine (Prozac) for a menstrual mood disorder. I also suffer from Migraines during this time too. The pharmacist told me it was not safe to take Relpax or Maxalt for migraines while on Prozac because of possible Serotonin Syndrome. However, my doctor said it would be okay because the Prozac is at such a low dose. Does this sound legitimate or what? I’m very worried about mixing these.

    Thanks!
    Leah

    Leah Sellars

    13 Mar 09 at 3:12 pm

  34. Leah,

    If you are uncomfortable about this, no matter what the dose, let your doctor know. Tell your doctor if there are other options that can help you avoid this potential for serotonin syndrome, no matter how “remote” that chance is. It’s better that you have some peace of mind. If your doctor insists, ask that he monitor you very carefully at the beginning of therapy to make sure that you’re adjusting well and that nothing problematic occurs.

    Jane

    Jane Chin, Ph.D.

    17 Mar 09 at 2:54 pm

  35. Hello there! I’m very sick with bipolar and all the meds I take. I feel like I’m poisoned. I talk to my psychiatrist at least monthly and have frequent med changes. I take Topomax 200mg qd, Risperdahl 2mg hs, Wellbutrin 300mg qd, Zoloft 300 mg qd, Promethium100mg qd, Suboxone 8 mg qd, Xanax 2mg bid, other things I can’t remember, and very occasionally Ultram and Lyrica. I have nystagmus, vertigo and uncoordination episodes every 4-6- weeks. I just saw a neuro guy and her just said probably a med reaction and shuffled me off. I have anxiety and panic attacks every day since my husband and father died withid 4 weeks of each other 1 1/2 years ago when this snow balled= I haven’t been able to bounce back. I have no energy, I sit all day, started smoking, don’t eat. answer the door or phone. I can’t bear this life. Idon’t connect to antone or anything. I have a twenty year old son in college who stayed at hoe and helped me take care of his Dad through the year of lung cancer, I have a daughter who is so happy in her new merriage and 8 month old baby. So I wouldn’t commit suicide because I wouldn’t hurt them. but I don’t want to live like this. I feel like i have some serotonin syndrome, but I live in a small rural community and maybe they are uninformed. Do you have any thing to say that might help? I’m desparate.

    Margo

    30 Mar 09 at 7:08 pm

  36. Margo, I’m not sure what I can say to what you have gone through. You’ve gone through 2 major tragedies as well as other major life transitions (children moving out, therefore empty nest) in such a short time. What you are going through is a tremendous snowball of GRIEF that you must deal with. Are you getting any support from support groups for people who have lost their spouses, to start?

    Jane Chin, Ph.D.

    25 Apr 09 at 10:50 am

  37. I have been taking 7 day trial 30mg cymbalta and prescibed 20mg Prozac together, I see it is one of the drugs you dont mix together, but it doesnt seen to effect me in no serious way. Also the 20mg Prozac isnt doing to well by it’s self is why I mix them together. The only side effect I seem to have with them being mixed together is sleepiness. Would I have to watch out later for any serious problems in the long run?

    Joanne

    16 Jun 09 at 12:15 am

  38. My partner is in real trouble and needs help. She is a 38 year old woman, intelligent, functioning yet refuses to listen to warnings I have tried to give her. She is presently being prescibed Cipralex (10 mg.) for treatment of depression. She is a marijuana user (3-4 times daily), drinks (not everyday, but excessively at least 2 times weekly), is a heavy smoker, is on the birth control pill, takes migraine medication, and has been using cocaine. I don’t think she has advised her doctor of all the drugs she is using and he does very casual follow up visits (every couple of months). Is she putting herself in imminent danger?

    Darren

    29 Aug 09 at 3:22 am

  39. Darren: if what you have described is an accurate description of the actions that your partner is taking, then my personal, non-medical opinion (i.e. common sense) is – yes, she is putting herself and potentially others who may be in her way when she is under the influence of drugs and/or alcohol – in danger. I am sorry to hear this is happening with her.

    Jane Chin, Ph.D.

    11 Sep 09 at 10:05 pm

  40. I am 200lbs male, 23 yrs old. I have been put on celexa. My current dosage is 20mg. I am in my 3rd month and I haven’t notice any positive change (just side effects like nausea, numbness in the fingertips, slight tingling feeling i temple areas, disappearing trains of thought.) . In fact; my attacks seem even worse then when I started. I have two questions regarding celexa.

    1. Do i ask my doctor for a different medication or just to increase the dosage ( I have read positive testimonials that the doctor increased dosage by 20mg-60mg and they had a better result)

    2. I get many headaches and when I am sick I take cold medication. Most of the pain and cold&flu/allergy drugs contain Acetaminophen. SUDAFED( 500mg acetaminophen ) BENEDRYL ( 500mg acetaminophen ) DAYQUIL (325mg ACETAMINOPHEN). what would be an approximate safe dosage of these drugs given my current dosage of Celexa ??(sometimes 2/3 in one day – allergies and cold) . I do not use these everyday, only when I feel they are needed due an inability to work (Stock Trading)

    George

    16 Sep 09 at 10:08 am

  41. My daughter is taking 3/25 symbyax and 20 mg’s of prozac at the same time, I am wondering is this why she is doing things that she does not remember… such as smoking in the middle of the night and does not remember getting up at all(mind you, my husband or I usually find her in the floor sleeping), opening the fridge and going to sleep in the middle of the floor. Last night she was in the livingroom floor and it appeared that she may of stood up and just fell. food plate was spilled all over the floor. She is not remembering anything. What should we do?????

    Tabitha

    14 Oct 09 at 10:58 am

  42. Dear George:

    1. it is true that many docs prefer to increase the dosage if the patient has shown that he is tolerating the current drug, rather than switching to a new drug. That said – your symptoms described in the side effect profile does NOT suggest to me that you are “tolerating well” this drug at the current dose! Nausea should subside with time, and 3 months is a very long time, but I’m concerned with the neurological symptoms you’re experiencing. I would not brush off these neurological symptoms – please tell your doctor about these!

    2. that’s something you want to ask your doctor OR the pharmacist – things to watch out for is the clearance/metabolism of the drugs – whether or not any or all of these affect the liver enzymes (common liver enzymes that clear drugs include Cytochrome P450 isozymes 2D6 and 3A4). sometimes one drug can affect the way one of these enzymes work – and if that enzyme affected happen to be the one needed to clear out another drug – celexa for example – then you may potentially have a high level of celexa built up in your system that can become dangerous. so with this one too – please ask your doctor or pharmacist as soon as possible.

    my thoughts are with you,
    Jane

    Jane Chin, Ph.D.

    19 Oct 09 at 10:20 pm

  43. How soon can i start taking cymbalta(30 mg 2x a day) after stoping effexor? My insurance company would’nt approve the cymbalta which was my doctor first choice, so I had to go on effexor. Now my insurance company approved it. I want to get off of the effexor.

    cbabybey

    15 Jan 10 at 7:03 pm

  44. I am taking 60mg of Cymbalta in the am and 40mg of Prozac and 200mg XR Seroquel. I feel great any issues?

    Ed

    25 Jan 10 at 5:30 pm

  45. taking prozac and Seroquel in the evening..

    Ed

    25 Jan 10 at 5:31 pm

  46. hi there, 2 1/2 years ago, i started a new job, it involved shifts and was a very stressful job and i developed sleeping problems, the g/p prescribed me a sleeping pill i think it was called zoplicone,i took this for about 3 months until the g/p decided to refer me to a psyciatrist for my sleeping problems, she told me i was addicted to zopliclone, and put me on seroquel, since then i have never felt right,i felt quite aggitated and nervous and plain weird, when i went back to see her, she told me to carry on taking it and prescribe me with citrolapam for anxiety, and discharged me from her care….but i am not happy as i always feel strange,i always feel tired,and not connected with the world which makes me feel aggitated, in two years my world as got smaller, i have now lost my job, through all this anxiety, and i never do anything, i dont go out,incase i feel weird and i havent been on a bus or train in ages for the same reason, it makes me anxious, and i know its all down to these tablets, im scared to just stop because of the side affects…. all because i had difficulty sleeping now my life is so small, and i used to have such a big life… i just want my normal happy life back please help

    karen

    21 Feb 10 at 9:48 am

  47. Dear Karen, If you think that the current med combination is not helping you and in fact has introduced new symptoms (problems, side effects) that is adding to the original problem of stress-related sleep problems, then you want to seek a second opinion about what you have been prescribed.

    Even with the adjustment to medications – you are supposed to feel “relief” from your original symptom as well as whatever new side effects that have emerged as a result of your body adjusting to the new medication. This usually takes 6-9 weeks. That your body has not adjusted and in fact your world seemed to have turned smaller and like a prison suggests that this medication combination needs to be immediately assessed.

    Jane Chin, Ph.D.

    22 Feb 10 at 1:50 am

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