SSRI/Effexor confusion

I am just reposting some of what I wrote in another thread here. I understand that doctors have different viewpoints, in that one doctor for example might say med A is their first choice, while another doctor might say Med A is their 3rd choice. But, for some doctors to say SSRIs (Newman, and many other doctors people have seen) are great and other doctors to say that SSRIs do not work (Rauch, etc), and can actually cause increased migraine symptoms (Buchholtz, etc) completely disturbs me. Such a blatant contradiction leaves me perplexed. I wonder if SSRIs help migraine apart from the anxiety component. Just wanted to see if anyone had any thoughts on this. I am very perplexed about whether I should try Nortriptyline again as my next drug (I only got up to 20mg in the past) or try Effexor. I’m afraid it’s probably more trial and error.

Hi Lisa,

Here is what I think. It is very confusing, and unfortunately there isn’t one magic pill for all of us. I believe that is why the doctors are conflicting; there simply isn’t a clear-cut answer. I sure wish there was, because I would be taking it right now! I have not taken either Nortriptyline or Effexor, so I can’t speak from experience. However, from what I have read both CAN be effective for some. Nortriptyline has been around longer, so it has a longer track record. My suggestion is for you to read through the potential side effects for each, talk to your doctor, pick one, and get started. It will be trial and error, unfortunately. Most importantly…follow your instincts.

From your posts, it seems you may be struggling with the idea of trying Effexor. I can understand why. I’ve been going through the same struggle. It seems to be the “hot” drug on the forum right now. Last summer, it was Topamax. Both work for some and are a nightmare for others. The only way to know how it will affect us is to try it. We just have to decide if we are willing to risk the potential side effects. For now, I’m going to continue my trial of zonisamide.

Good luck, Lisa. You seem to be a very smart woman. Go with your gut!

Marci :slight_smile:

Thanks Marci. I actually have tried Nortriptyline in the past, and the side effects were rough for me. But my body was adjusting to it; however, I saw a different doctor who thought that it wasn’t a good drug for me. I hated the side effects, but would tolerate it to get better. I definitely think Effexor is better tolerated, but everyone is different. I’ve tried so many drugs that I just want the next one to work, finally. wishing you all the best. thanks for responding

I wonder if the authors’ varying responses are based primarily on observations of their own patients’ reactions / success rates.

Obviously if some doctors (and reputable ones at that) ARE saying they’ve found clear evidence that these medicines work, then obviously they must’ve seen SOMEONE benefit from them, right? (In other words, the doctors who say these meds have often worked well … probably wouldn’t make that claim if they’d never seen any success in their own practice).

Keep in mind, Effexor is an SNRI, not an SSRI, so it affects both norepinephrine and serotonin.

Now, Hain has actually said that SSRI’s (or at least most of them) are fairly ineffective. But the SNRI Effexor, he says, is his traditional favorite and his usual first choice for migraine prevention (over verapamil and Topamax).

I would choose Effexor over an SSRI, personally. There does seem to be evidence that serotonin is significantly involved in the migraine process, but it also sounds to me (from what I’ve read) that a number of different neurotransmitters are involved (or become involved), which in my completely unprofessional opinion may be part of the answer why SNRI’s work (and better than SSRI’s, apparently).

(Not to conflate the issue, but consider what Hain says of verapmail vs. the very-similar flunarizine: “[It] is likely more effective than verapamil because it combines calcium channel and dopamine blocking activity.” This, again, to me suggests that medicines with multiple “brain-chemistry” effects are useful.)

All told, Hain says (and OK, he’s not omniscient, but he is very bright and well-versed) that SNRI’s have few side-effects.

I’m sure Scott would like to have a few words with me about my supporting the idea of trying Effexor, given that he said it pretty much took him to the inner circle of hell and back. However … Hain says the success rate is 80%, and I think the potential gain outweighs the potential risk, here.

In the end, though, I think you should trust your instinct on this, and if you have concerns, send a message to Hain (or leave a phone message – Cherchi called me back when I had a concern about verapamil).

Disclaimer (if I ever get sued): This was not medical advice.

Whatever you try, I sincerely hope it works for you and you have a whole lot of people here who really support you and will keep you in thoughts and prayers.

Oh, by the way, two other thoughts:

(1) IF you begin Effexor, you might ask Hain if he would be willing to consider starting you on the non-XR form so that you don’t “take the plunge” right at 37.5 from the get-go, especially if you’ve sensitivity to beginning new meds. And (2), you might also ask Hain about whether he thinks it might be beneficial to keep on the verapamil as well if you choose to try Effexor. The two have no contraindications / interactions with one another and Hain often combines two medicines when he feels one alone is not enough. (Given that the verapamil failed, it just might take a two-drug attack – but you could always try the Effexor alone first.)

George- you raise great points. I further wonder about Nortriptyline vs. Effexor. Nortriptyline also has multiple mechanisms of action.
I also wonder if I should stay on Verapamil. It hasn’t helped me at all, so i’m inclined to stop it. I have decreased it from 480 to 120. btw - I haven’t had any withdrawal from stopping it. I wonder if a drug that isn’t helping AT ALL can help in combination with another drug.

Here’s the way I see it regarding the verapamil:

If it’s not helping you, then clearly it’s not good enough on its own.

But if it’s also not HURTING you (i.e., it’s not causing side effects or bad reactions), then you have nothing to lose by keeping it going alongside the Effexor. Right?

If the verapamil didn’t work for you, and it’s got a pretty high success rate, then maybe any one given drug isn’t enough. Which means that you may stand a better chance with two meds together (than with any one pill by itself). The verapamil could work with the Effexor, but it won’t work against it.

Of course, whatever you do, you should make sure you get Hain’s go-ahead before going on two meds at once. I don’t think he’d have a problem with you doing that, but then again, I’m not the expert, am I!

Oh, also (I’m the perpetual “P.S.” man, apparently):

In his Web site’s discussion of amitriptylines, Hain says, “similar tricyclic type drugs include nortriptyline…” and comments that “We mainly use this drug when our favorites fail.” (The “favorites” are verapamil, Topamax and Effexor.)

A study of venlafaxine vs. amitriptylines found both effective, but that Effexor/venlafaxine had substantially fewer side effects, or that they were more tolerable. That doesn’t apply perfectly because nortriptyline isn’t exactly the same, but it’s apparently similar, though; both are tricyclics. Nortriptyline, actually, is also an antidepressant – the same classification as Effexor is – so they probably affect neurotransmitters fairly similarly.

I don’t know, but since you’re currently with Hain (you are, right?), then presumably, if he thinks Effexor is the one to start with, he’s probably made that decision based on a well-reasoned and thought-through approach, not just a flip of the coin. I’m told that when deciding between his three favorite medicines to start, he usually goes with Effexor first but ultimately makes the decision based on the individual (which one he thinks is most appropriate to that particular patient). It sounds like he goes for tricyclics occasionally but not as a top-of-the-heap / first-choice drug category.

Was that useful? Probably not. I confuse even myself (though it’s not hard to do so).

Hi Lisa,

I can’t see how staying on Verap would be worthwhile for you with or without another drug in the mix. We’d have to assume that somehow Effexor augmented Verapamil or vice versa. I’ve never read anything in the science lit suggesting this might occur although it’s an interesting idea George. As you said, you’d have to let Hain or your own doc make the call. It sounds like Hain pulls the plug on Verap after one month if there are no signs of improvement.

I think Marci’s advice on all of these differing med opinions is exactly right. There is simply no hard and fast rule. A migraine brain is very sensitive to changes and so it makes trialling meds very hard and feels like trying to walk through a mine-field while blind-folded. :?

My own experience so far with effexor is that it does have a very good effect on cleaning up symptoms. Unfotunately for me when I start increasing the dose side effects kick in. If it weren’t for those SEs I think this drug would be a real winner for me. Dropping the dose has caused me no troubles at all unlike the SSRIs even though you’ll read that Effexor is a nightmare to come off of. Not so in my case!

Dr Rauch didn’t say SSRIs don’t work for MAV, he said he was “unaware” of their possible efficacy in MAV patience and therefore hasn’t used them. Baloh and Newman, on the other hand, do use them so definitely worth you considering if you want to go there too at some stage.

You’ll get there Lisa … just have to get your current migraine cycling to stop.

Scott 8)

This is primarily what I was referring to, Scott (from Hain’s site):

“The author of this review usually starts patients with topamax, and proceeds on to try effexor, verapamil, propranolol and then ami or nortriptyline. It is very unusual that headache control is not attained. When one ‘group’ doesn’t work, he may combine two or 3 groups simultaneously (anticonvulsant, blood-pressure agent, antidepressant).”

Both Hain and the medical assistant at the practice (the latter was the one who returned one of my calls) said about as much – when one medicine alone fails, we either switch medicines or combine.

I’m probably about to way overstep my bounds in terms of my knowledge vs. yours (Scott), but from my limited perspective, I don’t see any hard-and-fast reason why verapamil shouldn’t have at least the potential to be useful – especially if staying with it isn’t producing any negative effects.

Hi George,

— Begin quote from “georgekoch”

I’m probably about to way overstep my bounds in terms of my knowledge vs. yours (Scott), but from my limited perspective, I don’t see any hard-and-fast reason why verapamil shouldn’t have at least the potential to be useful – especially if staying with it isn’t producing any negative effects.

— End quote

I really don’t know how they go about this to be honest. I always assumed that if one was to be using multi-pharmacy that you would be experiencing at least some sort of measurable effect from each as they were added. I guess I base this on Howie’s experience where his meds were added incrementally and, with each addition, he felt better and better (is that right Howie?). But maybe they do prepare “cocktails” when monotherapy fails and those cocktails end up being effective beyond the sum of their individual parts. A question for Hain perhaps?

Scott :slight_smile:

Sadly, Hain and Cherchi did not provide me with ANY definitive answers. they said that if you want to stay on Verapamil you can, and if you don’t stop it. I don’t think they could answer the questions, so I guess we surely can’t. Although, George, you do a great job trying. Dr. Buchholtz had told me that if Verapamil is helping in the slightest stay on it when adding another, but if it isn’t helping at all then drop it. I figure since Verapamil isn’t giving me any trouble (except the constipation which is letting up on a lower dose), I might as well test out George’s theory (something I theorized about too) and stay on a small dose.

Lisa, this disease is poorly understood, and it probably isn’t entirely the same for every maver (even for every maver who has constant symptoms). I can imagine that those doctors who dont think ssri’s help at all for mav, could have drawn that conclusion from studies that have shown that (at least some?) ssris dont help for migraine per se. It’s possible that they can be benifitial for the dizziness, without being so as much for headaches, thus there really isn’t a conflict there.

Other doctors promoting these types of drugs obviously has seen results from them, or they wouldnt use them. I dont think those who oppose them actually have used them on that many patients … I would also assume that not all ssri’s are equally beneficial (?)

So the conflict could be because of how you interpret migraine-studies; especially as there to my knowledge hasn’t been any studies regarding ssri’s (where many are included) and their effect on MAV-dizziness.

MikaelHS - I do agree that those doctors disputing certain drugs might not have tried them. You raise another good issue - is MAV treated the same as your more normal head pain. According to the doctors I saw a migraine is a migraine no matter what the symptoms, so MAV is treated the same as any other symptom of migraine.

— Begin quote from “scott”

Hi George,

— Begin quote from “georgekoch”

I’m probably about to way overstep my bounds in terms of my knowledge vs. yours (Scott), but from my limited perspective, I don’t see any hard-and-fast reason why verapamil shouldn’t have at least the potential to be useful – especially if staying with it isn’t producing any negative effects.

— End quote

I really don’t know how they go about this to be honest. I always assumed that if one was to be using multi-pharmacy that you would be experiencing at least some sort of measurable effect from each as they were added. I guess I base this on Howie’s experience where his meds were added incrementally and, with each addition, he felt better and better (is that right Howie?). But maybe they do prepare “cocktails” when monotherapy fails and those cocktails end up being effective beyond the sum of their individual parts. A question for Hain perhaps?

Scott :slight_smile:

— End quote

Scott:

I am not sure but I was on Zoloft when I went to see Newman and I was better on Zoloft but like 80%. He said he uses Zoloft and added Verapami. I am usually very functional on both like 95% most days unless I am triggered.