A Migraine and medication question just came in for our Ask the Clinician column. There is so much confusion about this that it's become necessary to address it yet again to help you wade through the confusion and take care of yourselves as well as possible. Here's the question:

"I have been taking 60 milligrams of Cymbalta daily to treat depression, having switched from Zoloft due to a substantial weight gain. I also suffer from migraine headaches, which my doctor prescribed Imitrex. After some research I have found that Cymbalta and Imitrex should not be used together. I also have Malignant Hyperthermia, and am especially concerned about taking medications which could lead to very serious complications. What are my options in migraine relief? I currently get 10 to 15 migraines each month. Kristina."

The issue of taking both triptans (Imitrex, Maxalt, Zomig, etc.) and SSRI and SNRI antidepressants is nowhere near as complicated as some people, including some doctors and pharmacists, are making it. Somehow, people get the same impression that Kristina did, that antidepressants and triptans "should not be used together." So, let's see if I can clarify this yet again.

Maybe one thing we need to look at is a couple of different types of "warnings" that can be in the prescribing information for our medications:

• Contraindications. Contraindications are a part of the prescribing information for medications and should be listed on the patient information sheets that pharmacies are required to give us when we pick up our prescriptions. Contraindications are circumstances under which a medication or treatment should not be used or could be harmful. In other words, contraindications mean do not take the medications in question together. Period.
• Warnings. There are often warnings in the prescribing information and patient information about mediations. These warnings do not mean that the medications in question should not be taken together. These warnings generally explain what symptoms would occur if taking specific medications were to cause a problem. In this case, our doctors should explain the potential problem, what symptoms to look for, and what constitutes a situation in which we should call them or seek emergency care.

So, back to the question of taking both antidepressants and triptans. Using these medications together is NOT contraindicated. There IS a WARNING about using them together. The potential problem is serotonin syndrome. When prescribing these medications, our doctors should describe the potential symptoms of serotonin syndrome, and tell us what to look for and when to call them about problems.

Here is what the FDA APPROVED prescribing information, which doctors and pharmacists use, for Imitrex says about serotonin syndrome:

Serotonin Syndrome: The development of a potentially life-threatening serotonin syndrome may occur with triptans, including treatment with IMITREX, particularly during combined use with selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs). If concomitant treatment with sumatriptan and an SSRI (e.g., fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram, escitalopram) or SNRI (e.g., venlafaxine, duloxetine) is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases. Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (e.g., hyperreflexia, incoordination), and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea).

Here is what the patient information, which you should receive when you fill a prescription for Imitrex says: