What changes can be made to the medication regimen of a patient taking bupropion (Bupropion) SR 100mg, duloxetine (Duloxetine) 90mg, and Lunesta (Eszopiclone) 1mg, who is experiencing more frequent migraines and dizziness?

Medication Adjustment for Migraine and Dizziness

The bupropion SR 100 mg dose is subtherapeutic and likely causing the migraines—increase it to 150 mg once daily for 3-7 days, then advance to 150 mg twice daily, as taking only 100 mg once daily creates unstable drug levels that contribute to headaches. 1

Immediate Medication Changes

Bupropion Dose Optimization

• The current 100 mg once-daily dose is below the standard therapeutic range and creates unstable drug levels that trigger afternoon headaches. 1
• Increase to 150 mg once daily first, then advance to 150 mg twice daily after 3-7 days (with the second dose taken before 3 PM to minimize insomnia). 1
• Headache, dizziness, nausea, and insomnia are among the most common adverse events with bupropion, but proper dosing reduces these effects. 2
• The standard therapeutic dose is 150 mg twice daily—this stabilizes drug levels and paradoxically reduces headache frequency compared to subtherapeutic dosing. 1

Duloxetine Consideration

• Duloxetine 90 mg is above the standard 60 mg dose but within the therapeutic range (60-120 mg). 3
• Duloxetine itself can cause dizziness as a common adverse effect, but it has shown efficacy in reducing migraine frequency in nondepressed individuals at doses of 60-120 mg. 3
• If migraines persist after optimizing bupropion, consider that duloxetine may be contributing to dizziness, though it may simultaneously be helping prevent migraines. 3

Eszopiclone (Lunesta) Assessment

• The 1 mg dose is low and unlikely to be the primary cause of migraines or dizziness.
• However, residual morning sedation could contribute to dizziness—assess timing of symptoms relative to sleep medication use.

Acute Headache Management

First-Line Treatment

• Use NSAIDs (ibuprofen, naproxen sodium, or aspirin) as first-line treatment for the current migraines—these have the strongest evidence for medication-induced headaches. 1, 4
• Acetaminophen alone is ineffective and should not be used as monotherapy. 1, 4
• Limit acute headache medication use to no more than 2 days per week to prevent medication-overuse headache. 1, 4
• Simple analgesics should be used fewer than 15 days per month. 5, 4

Preventive Therapy Consideration

When to Start Prevention

• If headaches persist after proper bupropion dosing and continue for 2 or more attacks per month producing disability for 3+ days per month, start preventive therapy. 1, 4
• Preventive therapy is also indicated if acute medications are being used more than twice per week. 4

First-Line Preventive Options

• Amitriptyline 30-150 mg/day has the strongest evidence for headache prevention and is particularly beneficial when psychiatric comorbidity exists (depression, anxiety). 1, 6, 4
• Start with 10-25 mg at bedtime and gradually increase to 30-150 mg/day as tolerated. 6
• Beta-blockers (propranolol 80-240 mg/day) are effective alternatives, though they can cause lethargy, depression, and dizziness—potentially worsening the current dizziness complaint. 5, 6
• Topiramate has Level A evidence for chronic migraine but causes cognitive inefficiency, paresthesia, and fatigue. 5

Critical Monitoring Points

Medication Overuse Prevention

• Completely avoid medications containing barbiturates, caffeine, butalbital, or opioids, as these carry the highest risk of causing medication-overuse headache. 4
• Triptans, if prescribed for severe headaches, must be limited to fewer than 10 days per month. 5, 4

Neuropsychiatric Monitoring

• Monitor for worsening depression, anxiety, suicidal ideation, agitation, irritability, or mood changes, particularly in the first 1-2 months after bupropion dose adjustment. 1

Common Pitfalls to Avoid

• Do not continue subtherapeutic bupropion dosing—this is likely the primary cause of the migraines. 1
• Do not add preventive therapy before optimizing the bupropion dose and allowing 2-3 weeks for assessment. 1
• Do not use acetaminophen alone for headache treatment—it is ineffective as monotherapy. 1, 4
• Avoid starting beta-blockers if dizziness is a prominent complaint, as they can worsen this symptom. 5