Can Contrave Worsen Migraines?
Yes, Contrave (naltrexone/bupropion) lists headache as a common adverse effect and can potentially worsen pre-existing migraines, particularly given the patient's history of chronic migraines. 1
Evidence for Headache as an Adverse Effect
Headache is explicitly listed as a common adverse effect of Contrave (naltrexone/bupropion combination) in the 2018 American Diabetes Association guidelines, appearing in the adverse effects profile alongside nausea, constipation, and vomiting 1
The bupropion component specifically has been associated with neurological adverse effects including acute dystonia, neck stiffness, and jaw muscle tightness in case reports, suggesting potential for exacerbating headache conditions 2
Clinical Considerations for This Patient
Patients with pre-existing migraine diagnosis are at higher risk for medication overuse headache, which is a critical consideration when adding any medication that can trigger or worsen headaches 1
The combination of chronic low back pain, migraines, and history of anxiety/depression (common indications for bupropion) represents multiple high-risk factors for developing medication-related headache complications 1
Risk-Benefit Assessment
While the naltrexone component at low doses (4.5 mg or less) has been studied for chronic pain management with minimal adverse effects 3, Contrave contains significantly higher doses of naltrexone (32 mg total daily) combined with bupropion (360 mg total daily), which increases the likelihood of adverse effects 1
The patient's chronic low back pain history is relevant, as bupropion SR showed no significant efficacy for non-neuropathic chronic low back pain in controlled trials 4, questioning whether the potential benefits outweigh the headache risk
Monitoring Recommendations
If Contrave is prescribed despite migraine history, closely monitor headache frequency (days per month), severity, and any changes in migraine pattern within the first 2-4 weeks of initiation 1
Discontinue Contrave immediately if migraine frequency increases to ≥7 days per month or if new neurological symptoms develop, as this represents a high-risk threshold for medication overuse headache 1
Document baseline migraine frequency before starting Contrave to objectively assess any worsening 1
Alternative Considerations
For weight management in patients with migraines, consider alternatives with lower headache risk profiles, though most weight-loss medications list headache as a potential adverse effect 1
Topiramate-containing regimens (Qsymia) may offer dual benefit as topiramate is recommended for migraine prevention, though it carries its own risks including paresthesia and teratogenicity 1