I’m a man taking bupropion, atomoxetine, testosterone, DHEA, B‑complex vitamins, and anastrozole and now have eye‑muscle twitching, headache, nausea, eye pain, tearing, a loopy feeling, and short‑term memory loss—what is causing this and what should I do?

Urgent Evaluation Required: Likely Drug-Induced Neurological Emergency

Stop bupropion and atomoxetine immediately and seek emergency medical evaluation today—your constellation of eye twitching, headache, nausea, eye pain, watery eyes, feeling "loopy," and memory loss suggests either serotonin syndrome, acute angle-closure glaucoma, or seizure prodrome, all of which require urgent assessment. 1, 2, 3

Immediate Actions Required

Discontinue High-Risk Medications Now

• Stop bupropion immediately because it can cause seizures (0.1% risk at 300 mg/day), visual disturbances including acute angle-closure glaucoma, and severe neurological symptoms 1, 2, 3
• Stop atomoxetine immediately as the combination with bupropion may precipitate serotonergic toxicity, though atomoxetine alone has minimal serotonin effects 4
• Do not abruptly stop any benzodiazepines if you are taking them, as this increases seizure risk with bupropion 3

Seek Emergency Evaluation for These Red Flags

• Eye pain with headache and visual changes (watery eyes, twitching) suggests acute angle-closure glaucoma, which bupropion can precipitate—this is a medical emergency requiring immediate ophthalmologic evaluation 1, 2, 3
• "Feeling loopy" with memory loss and nausea may represent early serotonin syndrome (confusion, altered mental status) or seizure prodrome 1, 2, 4
• Muscle twitching (eye twitching) combined with confusion can indicate neuromuscular hyperactivity seen in serotonin syndrome 4

Most Likely Diagnoses Based on Your Medication Regimen

1. Acute Angle-Closure Glaucoma (Highest Priority)

• Bupropion is absolutely contraindicated in closed-angle glaucoma and can precipitate acute attacks 2, 3
• Your symptoms of eye pain, watery eyes, headache, and nausea are classic for acute angle-closure glaucoma 1, 2
• This requires emergency ophthalmology evaluation within hours to prevent permanent vision loss 1, 2

2. Serotonin Syndrome from Bupropion-Atomoxetine Interaction

• Although bupropion has "minimal serotonergic activity," it inhibits cytochrome P450 2D6, which increases blood levels of atomoxetine and can precipitate serotonin syndrome 4
• Your symptoms of confusion ("loopy"), memory loss, nausea, and muscle twitching (eye twitching) fit early serotonin syndrome 4
• Serotonin syndrome typically develops within 24-48 hours of adding or increasing doses 4

3. Seizure Prodrome or Post-Ictal State

• Bupropion causes seizures in approximately 1 in 1,000 patients at standard doses 1, 2, 3
• Memory loss and feeling "loopy" may represent a post-ictal state after an unwitnessed seizure 3, 5
• Eye twitching can be a focal seizure manifestation 3

Critical Risk Factors in Your Medication Regimen

Testosterone and Anastrozole Increase Seizure Risk

• High-dose testosterone can lower seizure threshold, compounding bupropion's seizure risk 3
• Anastrozole (aromatase inhibitor) may affect neurosteroid levels and further reduce seizure threshold 3

DHEA and B-Complex May Contribute

• DHEA has neurosteroid effects that can interact with seizure threshold 3
• High-dose B6 (if present in your B-complex) can paradoxically cause neurological symptoms including confusion and neuropathy at doses >200 mg/day

What Your Emergency Provider Needs to Know

Medication History to Report

• Current medications: Bupropion (dose?), atomoxetine (dose?), testosterone (dose and formulation?), anastrozole (dose?), DHEA (dose?), B-complex (specific formulation?)
• Duration: How long on each medication? Any recent dose changes?
• Timing: When did symptoms start relative to medication changes?

Symptoms to Emphasize

• Eye pain with headache and watery eyes (glaucoma red flag) 1, 2, 3
• Altered mental status ("loopy," memory loss) 4
• Neuromuscular symptoms (eye twitching) 4
• Autonomic symptoms (nausea) 4

Tests Your Provider Should Order

• Immediate ophthalmology consultation with intraocular pressure measurement and slit-lamp examination 1, 2
• Neurological examination including mental status, reflexes, and clonus assessment 4
• EEG if seizure suspected 3, 5
• Basic metabolic panel to rule out electrolyte disturbances 4
• Testosterone and estradiol levels to assess if supraphysiologic dosing is contributing 3

After Emergency Evaluation: Next Steps

If Glaucoma is Confirmed

• Bupropion is permanently contraindicated 2, 3
• Switch to an alternative antidepressant without anticholinergic effects (e.g., sertraline, escitalopram) 1, 2

If Serotonin Syndrome is Confirmed

• Both bupropion and atomoxetine should be discontinued 4
• Cyproheptadine (serotonin antagonist) may be administered 4
• Allow 10-14 day washout before starting alternative antidepressant 1

If Seizure is Confirmed

• Bupropion is permanently contraindicated after a seizure 3
• Do not restart bupropion under any circumstances 3
• Consider alternative antidepressants (SSRIs, SNRIs) that do not lower seizure threshold 1, 2

Common Pitfall to Avoid

Do not attribute these symptoms to "stress" or "anxiety" and continue medications—the combination of eye pain, headache, altered mental status, and muscle twitching in a patient on bupropion represents a medical emergency until proven otherwise 1, 2, 3, 4. The earliest manifestations of serotonin syndrome are often misinterpreted as worsening of the underlying psychiatric condition, leading to dangerous escalation of causative medications 4.