Can Sertraline Aggravate Migraines?
Yes, sertraline can potentially worsen migraine attacks, particularly during acute administration, though it is generally considered ineffective rather than harmful for migraine prevention. 1
Evidence for Migraine Exacerbation
A case report documented a patient who developed frequent migraine attacks during treatment with sertraline for depression, suggesting that acute administration of SSRIs in migraineurs may include the risk of worsening migraine. 1
This paradoxical worsening appears to occur despite the theoretical rationale that serotonergic modulation should help migraines, highlighting the complex role of serotonin in migraine pathophysiology. 1
Efficacy Evidence for Migraine Prevention
Sertraline has been studied for migraine prophylaxis but showed no significant improvement in headache frequency or severity over placebo, with headache index scores remaining essentially unchanged over 8-12 weeks of treatment. 2
SSRIs as a class, including sertraline, are not as effective as conventional migraine prophylaxis medications such as beta-blockers, tricyclic antidepressants, or divalproex sodium. 2
For chronic tension-type headache (often comorbid with migraine), sertraline showed no difference compared to placebo in reducing headache frequency at 8 weeks of follow-up. 3
Clinical Context and Recommendations
If you are considering sertraline for a patient with migraines, be aware that it may worsen migraine frequency rather than help, particularly during the initial treatment period. 1
Sertraline may only be considered in patients with comorbid depression who have failed conventional migraine prophylaxis therapy, though even in this scenario, evidence for efficacy is lacking. 2
First-line migraine prevention should utilize amitriptyline (30-150 mg/day), propranolol (80-240 mg/day), or divalproex sodium, all of which have strong evidence for efficacy. 4, 5, 6
Important Clinical Pitfalls
Do not assume that SSRIs will help migraines simply because they modulate serotonin—the relationship between serotonin and migraine is complex, with serotonin levels decreasing during attacks despite serotonin being a vasoconstrictor. 7
Monitor patients closely if sertraline must be initiated for depression in a migraineur, as migraine frequency may increase and require additional acute treatment with triptans. 1
Avoid using sertraline as a migraine preventive agent when evidence-based alternatives with proven efficacy are available. 4, 2