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 potential for headaches as a side effect, and closely monitoring the patient's symptoms, as suggested by the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1. The patient's experience of headaches worsening after the dose increase to 75mg and the subsequent relief during school breaks suggests that the headaches may be related to both the medication and situational factors, such as school-related stress. Given that headaches are a common side effect of sertraline, affecting a significant portion of patients, it is crucial to balance the need for effective OCD treatment with the management of side effects. The guideline recommends starting with a subtherapeutic dose as a “test” dose and increasing the dose slowly, which aligns with the approach of gradually increasing the sertraline dose while monitoring headache symptoms closely 1. Some key points to consider in the management of this patient include:

• Gradually increasing the sertraline dose, considering increases on weekends first when stress is lower, then extending to weekdays if tolerated.
• Monitoring headache symptoms closely and adjusting the dose as needed.
• Ensuring the patient takes the medication with food and maintains adequate hydration.
• Using appropriate over-the-counter pain relievers like acetaminophen when needed for immediate headache management.
• Considering splitting the dose (37.5mg twice daily) if headaches persist or worsen, to maintain therapeutic levels while reducing peak concentrations that might trigger headaches.
• Exploring stress management techniques and possibly involving a therapist for complementary cognitive-behavioral therapy to address both OCD symptoms and potential school-related stressors, as supported by the guideline's emphasis on the importance of addressing underlying issues 1. Ultimately, the goal is to reach therapeutic doses for effective OCD treatment while minimizing side effects, and this requires a careful and individualized approach, taking into account the patient's specific needs and circumstances, as well as the potential risks and benefits of sertraline treatment, including the risk of suicidal thinking and behavior, which is a boxed warning for SSRIs in patients through age 24 years 1.

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 and headache 3, 4, 5.
• The studies focus on the efficacy of sertraline in treating obsessive-compulsive disorder (OCD) and do not provide detailed information on headache as a side effect.

Increasing Dose of Sertraline

• The studies suggest that an adequate drug trial involves administering an effective daily dose of sertraline for a minimum of 8 weeks 3.
• Increasing the dose of sertraline may be necessary to achieve optimal treatment of OCD, but it is essential to monitor the patient's response and adjust the dose accordingly 4, 5.
• The patient's headache may be related to the increase in dose, but without further information, it is difficult to determine the cause of the headache.

Treatment of OCD

• Sertraline is a commonly used medication for the treatment of OCD, and the studies suggest that it is effective in reducing symptoms of OCD 3, 4, 5.
• The patient's response to sertraline should be monitored, and adjustments to the dose or treatment plan may be necessary to achieve optimal results.
• It is essential to take a comprehensive patient history to understand the patient's symptoms, medical history, and response to treatment 6, 7.