Is a headache in a 15-year-old patient with Obsessive-Compulsive Disorder (OCD) likely due to sertraline (Zoloft), given that the headache worsened after the dose was increased to 75 milligrams?

From the Guidelines

I strongly recommend a cautious approach to increasing the sertraline dose, considering the patient's history of headaches that worsened after the dose was increased to 75mg, and discussing alternative strategies with the prescribing physician. The patient's experience of headaches improving during a school break suggests that school-related stress or tension headaches might be a contributing factor, rather than solely a medication side effect 1. However, it is essential to acknowledge that sertraline can cause headaches as a side effect, particularly when doses are increased, as noted in the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1.

Given the need to continue treating OCD, the following steps can be considered:

• Continue with the planned dose increases under medical supervision, while closely monitoring the patient's headache symptoms and adjusting the treatment plan as needed.
• Track headaches in relation to school, stress levels, and medication timing to better understand potential triggers and correlations.
• Consider slowing the rate of dose increase, ensuring adequate hydration, or adding a mild analgesic as needed, under the guidance of the prescribing physician.
• Explore alternative strategies, such as taking the medication at a different time of day if headaches occur at specific times, to minimize potential side effects.

It is crucial to prioritize the patient's safety and well-being, considering the potential risks associated with sertraline, including suicidal thinking and behavior, behavioral activation/agitation, and serotonin syndrome, as highlighted in the clinical practice guideline 1. By adopting a cautious and supervised approach, the patient's OCD treatment can be effectively managed while minimizing potential risks and addressing the headaches.

From the FDA Drug Label

Headache2523

Table 4 lists the adverse events associated with discontinuation of sertraline hydrochloride treatment (incidence at least twice that for placebo and at least 1% for sertraline in clinical trials) Adverse Event... Headache1%2%--1%--2%

It is possible that the headache is due to sertraline, as headache is listed as a treatment-emergent adverse event in the drug label, with an incidence of 25% in patients taking sertraline compared to 23% in patients taking placebo 2. However, the incidence of headache is not significantly higher in the sertraline group compared to the placebo group.

• The patient's headache worsened after the dose was increased to 75mg, which suggests a possible correlation with the medication.
• However, the headache resolved when the patient was off school, which could indicate that the headache is related to other factors, such as stress or environment. Given the uncertainty, it is recommended to exercise caution when increasing the dose of sertraline, and to monitor the patient's symptoms closely for any changes. If the headache persists or worsens, alternative treatments or adjustments to the current treatment plan may be necessary.

From the Research

Headache as a Side Effect of Sertraline

• Headache is a possible side effect of sertraline, but the provided studies do not specifically address the relationship between sertraline dose and headache incidence 3, 4.
• The studies focus on the efficacy and safety of sertraline in treating obsessive-compulsive disorder (OCD), with headache mentioned as a potential side effect, but not thoroughly investigated 3, 4, 5.

Dose Increase and Headache

• The patient's headache worsened after the dose was increased to 75mg, but it is unclear if this is directly related to the sertraline dose increase 3, 4.
• A study on the optimal dose of serotonin reuptake inhibitors for OCD found that the dose-efficacy curve showed a gradual increase trend in the 0-40mg dose range, and then a decreased trend in doses up to 100mg fluoxetine equivalent 4.

Treatment of OCD

• The patient is being treated for OCD, and sertraline is a commonly used medication for this condition 3, 6, 7, 5.
• Combined treatment with cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) medication may be more effective than monotherapy, but the optimal treatment approach depends on individual patient needs and circumstances 6, 7, 5.

Next Steps

• Consider consulting the studies on optimal dosing of sertraline for OCD to determine the best course of action for the patient 4.
• Evaluate the patient's response to the current dose and consider alternative treatment approaches, such as combined therapy with CBT, if necessary 6, 7, 5.