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Use of Mirtazapine as Prophylactic Treatment for Migraine Headache

Key Words: Letters to the Editor • Mirtazapine • Migraines

TO THE EDITOR: Migraine headache is a common and often underrecognized problem that affects about 11 million adults in the United States.^1,2 Headaches are one of the most common medical complaints faced by physicians.³ There are many therapeutic options that may relieve migraine sufferers, such as vasoconstrictors, antidepressants, analgesics, anticonvulsant medications, biofeedback, relaxation techniques, and spinal manipulation.² We discuss a case in which Remeron® (mirtazapine) assisted in reducing the number of migraine headaches suffered by a patient.

Case Report

The patient is a 60-year-old man who had worked as a preacher until 5 years ago, when his wife left him because of marital difficulty. Since that time, he has had depressed mood, anhedonia, erratic sleep, decreased energy and concentration, feelings of guilt, and a weight problem. However, he exhibited no suicidal or homicidal ideation or intent. The patient also reported that because of these problems, he had driven away his children, extended family, and friends, leaving him isolated and withdrawn from society. He did not meet criteria for substance abuse or dependence, mania or hypomania, posttraumatic stress disorder, obsessive-compulsive disorder, or panic disorder. However, he did report problems with muscle tension and anxiety. His medical history was significant for hypoglycemia, increased cholesterol and triglycerides (diet-controlled), and migraine headaches.

Past medications included Elavil® (amitriptyline) and Paxil® (paroxetine) for migraine prophylaxis. However, because of side effects of cognitive dulling, dry mouth, and sexual dysfunction, he discontinued both medications and began taking St. John's Wort, which provided mixed results. His mental status exam was remarkable for sad facial expression, a "down" mood, a constricted affect, and a Mini-Mental Status Exam score of 29/30. The patient was diagnosed with major depressive disorder.

The initial treatment plan included discontinuation of the St. John's Wort, routine laboratory tests, and a magnetic resonance imaging (MRI) scan of the brain. Laboratory tests revealed no significant abnormalities, and the MRI was negative. The patient was started on mirtazapine (7.5 mg) at bedtime. Cognitive–behavioral therapy was also initiated. Over the next several months, the patient's depression improved with the prescribed medication and therapy. At one clinic visit, he reported that he had run out of medication before his appointment. After further inquiry, he reported that when he felt a migraine coming on, he would take an extra mirtazapine tablet to abort the headache. He noted that the frequency of his headaches had decreased from four to five headaches per month to about one per month. He attributed this change in frequency to the extra mirtazapine pill he had taken at the onset of the migraine symptoms. Furthermore, after being followed by a new psychiatrist, mirtazapine was discontinued, and bupropion initiated, which resulted in the reoccurrence of migraines.

DISCUSSION

The involvement of serotonin and norepinephrine neurotransmitters in migraine headaches would support treatment with antidepressants that work on either of these neurotransmitters.^4,5 Tricyclic antidepressants such as amitriptyline (Elavil®) have long been recognized as beneficial agents in the treatment of headache. However, the use of amitriptyline in treating headache, even at low dosages, may be associated with such side effects as increased QT interval, constipation, cognitive dulling, and dry mouth. These side effects may result in limitations of the use of amitriptyline, especially in elderly patients.⁶

Mirtazapine has both noradrenergic and serotonergic activity. By acting as a 5HT3 antagonist, mirtazapine blocks the serotonin activation of the 5HT3 receptor, thus relieving headaches that are commonly associated with such activation. Mirtazapine also has 5HT1A agonistic properties, and it is this aspect of mirtazapine that warrants serious consideration in the treatment of migraine headaches. Some investigators believe that migraine headaches are associated with the 5HT1 receptor, making migraine prophylaxis a use of mirtazapine. This is a novel idea, but additional research is needed to assert the full benefit of mirtazapine in this particular patient population.^8,9

This case study reports a favorable response to mirtazapine in a patient with migraine headaches. With this information and the other information presented, mirtazapine may be useful in migraine prophylaxis. Double-blind placebo-controlled studies are needed to fully evaluate the efficacy of mirtazapine in the treatment of patients with migraine headaches.

REFERENCES

1. Marks DR, Rapoport AM: Diagnosis of migraine. Sem Neurol 1997; 17:303–306[Medline]
2. Nelson CF, Bronfort G, Evans R, et al: The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. J Manipulative Physiol Therap 1998; 21:511–519[Medline]
3. Sturm JW, Donnan GA: Diagnosis and investigation of headache. Aust Fam Physician 1998; 27:587–589[Medline]
4. Nicolodi M, Sicuteri F: Fibromyalgia and migraine: two faces of the same mechanism. Serotonin as the common clue for pathogenesis and therapy. Adv Exp Med Biol 1996; 398:373–379[Medline]
5. Bendsten L, Jensen R, Olesen J: A non-selective (amitriptyline), but not a selective (citalopram), serotonin reuptake inhibitor is effective in the prophylactic treatment of chronic tension-type headache. J Neurol Neurosurg Psychiatry 1996; 61:285–290[Abstract/Free Full Text]
6. Bryson HM, Wilde MI: Amitriptyline: a review of its pharmacological properties and therapeutic use in chronic pain states. Drugs Aging 1996; 8:459–476[Medline]
7. DeBoer T: The pharmacological profile of mirtazapine. J Clin Psychiatry 1996; 57(suppl 4):19–25
8. Puzantian T: Mirtazapine, an antidepressant. Am J Health Syst Pharm 1996; 55:44–49
9. Stahl SM: Psychopharmacology of Antidepressants. London, UK, Martin Dunitz, Ltd., 1998, pp 70–79

This article has been cited by other articles:

				L. Bendtsen and R. Jensen Mirtazapine is effective in the prophylactic treatment of chronic tension-type headache Neurology, May 25, 2004; 62(10): 1706 - 1711. [Abstract] [Full Text] [PDF]

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