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picking a migraine med that won't interact with everything else

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hey! so i've had migraines for sevenish years, roughly since puberty happened. they've gradually increased in frequency and severity, and i'm having issues doing life shit, as exertion often triggers them or makes them worse, and i'm consuming a fairly significant amount of excedrin daily (3-10 pills, which i feel like probs won't be healthy to continue indefinitely) to keep things to a dull roar. i'm getting twoish nasty migraines a week and then a constant unpleasant headache that threatens to turn into a migraine if i don't slow my roll/take more excedrin/nap. so i'm looking into meds to deal with migraines but i don't have much experience and am having trouble narrowing down what i'm looking for. my psych suggested daily trazodone but my current med cocktail already fucks with my energy and wakefulness and i have cfs so it'd be nice to take something a little less likely to knock me out. things that need to be considered: tried amitriptyline, ended up in the psych ward for serious mood issues, can't do ssri's, etc because they make me pretty impressively manic. tried maxalt, didn't do anything. need some suggestions on stuff that's unlikely to interact super badly with the current med cocktail that i can mention to my psych. thanks! 

current meds:

latuda 40 mg

lithium 1200 mg

hydroxide 25 mg

relevant dxes:

bipolar 2


chronic fatigue syndrome

migraines (lol)

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I've personally never heard of trazodone being used for migraines but then again I'm no expert.

There are two ways to treat migraines: abortive and preventative treatments.

The triptans, like Maxalt, are abortive treatments, like you have a migraine and you need it to end right now.

These include sumatriptan (Imitrex), zolmitriptan (Zomig), naratriptan (Amerge), rizatriptan (Maxalt) (your favorite...), almotriptan (Axert), eletriptan (Relpax), and frovatriptan (Frova). In my non-educated guess, the ones metabolized with the least CYPs would be the ones least likely to interact with other meds, or at least the least CYPs anyway.

  • Triptans — metabolized by...
    • Imitrex — MAO-A
    • Zomig — MAO-A, CYP1A2
    • Amerge — many CYPs, MAO-A
    • Maxalt — MAO-A
    • Axert — CYP 2D6, CYP3A4, MAO-A
    • Relpax — CYP3A4
    • Frova — CYP1A2
  • Triptan/analgesic combos
    • Treximet ( sumatriptan/naproxen sodium )
  • Ergotamines
    • ergotamine/caffeine (Cafergot)
    • dihydroergotamine (D.H.E. 45)
    • Migranol (dihydroergotamine nasal)

I think Latuda and hydroxyzine are both metabolized by CYP3A4, so it would be best to avoid ones metabolized by it. You're not taking an MAOI, so you don't have to worry about MAO-A metabolization. My guess would be that Imitrex, Zomig, (Maxalt...), or Frova would be the best bets for abortive treatments for migraines.

The preventative treatments range from antidepressants (which you seem unable to tolerate) to blood pressure meds like beta-blockers to anticonvulsants.

  • Antidepressants
    • SNRIs
      • venlafaxine/venlafaxine ER (Effexor/Effexor XR)
      • Savella (milnacipran<— actually only indicated for fibromyalgia but I'm sure it can be prescribed off-label
        • Possibly...
          • duloxetine (Cymbalta)
          • desvenlafaxine succinate ER (Pristiq) / desvenlafaxine ER (Khedezla)
          • Fetzima (levomilnacipran)
    • Tricyclics
      • amitriptyline (Elavil)
        • Possibly,...
          • imipramine (Tofranil, Tofranil-PM)
          • nortriptyline (Pamelor)
          • desipramine (Norpramin)
          • protriptyline (Vivactil)
          • or possibly other Tricyclics,,,
  • Cardiac meds
    • Beta-blockers
      • atenolol (Tenormin)
      • nadolol (Corgard)
      • propranolol (Interal, Inderal LA)
      • metoprolol tartrate (Lopressor)
      • metoprolol succinate (Toprol-XL)
      • timolol
    • α2 agonists
      • guanfacine (Tenex)
        • (possibly clonidine (Catapres)?)
    • Calcium channel blockers
      • verapamil (many brands)
        • (possible amlodipine (Norvasc)?)
  • Anticonvulsants
    • divalproex sodium (Depakote/Depakote ER)
    • valproic acid (Depakene)
    • topiramate (Topamax/Trokendi XR/Qudexy XR)
    • carbamazepine (Tegretol/Tegretol XL/Carbatrol/Equetro) <— may interact with lithium
      • (I think I've heard of gabapentin (Neurontin) and Lyrica (pregabalin) being used for migraine prophylaxis...)
      • Zonisamide (Zonegran)

Miscellaneous meds listed in Epocrates:

  • Botox
  • Barbiturate/analgesic combos
    • butalbital/acetaminophen/caffeine (Esgic/Esgic-Plus/Fioricet/Orbivan)
    • butalbital/acetaminophen/caffeine/codeine (Fioricet with Codeine)
    • butalbital/aspirin/caffeine (Fiorinal)
    • butalbital/aspirin/caffeine codeine (Fiorinal with Codeine)
    • butalbital/acetaminophen (Phrenilin/Phrenilin Forte)
  • Opioids
    • butorphanol nasal (Stadol NS)
  • NSAIDs
    • diclofenac potassium (Cambia)
  • Isometheptene/dichloralphenazone/acetaminophen (Midrin)

That's just an exhaustive list of meds from Epocrates and from reading around on the Internet (sorry I couldn't provide links...) Some of these will interact with your meds, but they shouldn't interact too badly. The antidepressants I would definitely watch out for since you have a track record with mania with SSRIs (SNRIs and tricyclics might do the same for you), Trying another triptan for migrane abortion or an ergotamine might be a good idea, and adding a migraine prophylactic might be good too, I've heard good things about the anticonvulsants, some about the beta-blockers, not much about anything else though.

Good luck with finding a med that works for you! :) 

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My son took amitripytaline for years, helped some, but not entirely. Right now he takes OTC generic migraine relief, containing acetominophen, aspirin and caffeine. Doesn't ward them off, naturally is for when it is already starting, but fairly effective for reducing symptoms. 

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  • 4 weeks later...

Amitripyline made me feel suicidal so obviously not for me. I'm on a daily preventive, a beta blocker, propranolol. On it, I very rarely get migraines and I haven't had side effects or interactions. It's certainly something to discuss with whoever is prescribing your meds. Supposedly it helps with physical symptoms of anxiety, too, like the racing heart aspect, so I may benefit from that as well. At any rate, I appreciate not having migraines. 

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