From the Guidelines
I strongly recommend considering augmentation strategies for this 22-year-old female with treatment-resistant depression, prioritizing medications that can address both mood symptoms and migraines while being mindful of her seizure history. Given her current Lexapro regimen and history of failed SSRIs and Duloxetine, adding a medication with a different mechanism of action is crucial.
- Augmentation with aripiprazole (2-5mg daily) or quetiapine (50-150mg at bedtime) could enhance antidepressant efficacy, as suggested by recent clinical practices 1.
- Alternatively, mirtazapine (15-30mg at bedtime) might help with both depression and sleep while potentially reducing migraines, considering its unique pharmacological profile.
- Given her seizure history and migraines, lamotrigine (starting at 25mg daily, gradually titrating to 100-200mg daily over 4-6 weeks) could address both mood symptoms and provide migraine prophylaxis while being seizure-protective, aligning with the principles outlined in the Delphi-method-based consensus guideline for treatment-resistant depression 1.
- For her anxiety, continuing hydroxyzine is reasonable, but pregabalin (75mg twice daily, increasing as needed) might offer better sustained relief for both anxiety and potentially help with migraines, as supported by the American College of Physicians' clinical practice guideline on using second-generation antidepressants to treat depressive disorders 1. Close monitoring for side effects is essential with any medication change, particularly watching for increased suicidal ideation in the first few weeks. Encourage continuation with therapy alongside medication management, as the combination typically yields better outcomes than either approach alone, emphasizing the importance of a comprehensive treatment plan.
From the Research
Treatment Options for Patient with MDD, GAD, PTSD, and Daily Migraines
The patient has tried and failed several SSRIs and Duloxetine, and is currently on Lexapro with some improvement but still experiencing significant depression symptoms, low energy, and passive suicidal thoughts. Considering the patient's history of seizures, bupropion is being avoided.
- The patient's daily migraines are a significant concern, and the use of amitriptyline, a tricyclic antidepressant, was tried but caused worsened anxiety and night sweats 2.
- Studies have shown that SSRIs and SNRIs may be effective in preventing migraine headaches, with venlafaxine being more effective than escitalopram in reducing headache frequency, duration, and severity 3.
- However, other studies have found that SSRIs and SNRIs are no more effective than placebo or amitriptyline in reducing migraine frequency, intensity, and duration over two to three months of treatment 4.
- For patients with treatment-resistant depression, such as this patient, other treatment options may include switching to a different antidepressant, combining more than one antidepressant, or augmenting an antidepressant with another medication, such as an antipsychotic or lithium 5.
Potential Next Steps
Given the patient's complex presentation and lack of response to previous treatments, a shared decision-making approach is recommended to guide treatment selection and address the patient's individual needs 5.
- Consider augmenting the current Lexapro treatment with another medication, such as an antipsychotic or lithium, to enhance its efficacy.
- Alternatively, switching to a different antidepressant, such as venlafaxine, may be considered, given its potential benefits in reducing migraine frequency and severity 3.
- The patient's daily migraines should be prioritized, and treatment options that address both depression and migraine symptoms should be explored.
- Hydroxyzine is being used for anxiety with some benefit, and the patient has just started therapy, which is going well. These treatments should be continued and monitored for efficacy.