Before choosing any preventative treatments, it is important to eliminate frequent headache triggers. The most common triggers include irregular sleep, missed meals, caffeine, and chocolate. Other common triggers, which are not preventable, are menstrual cycles, weather fronts, and stress releases.

Once the most common preventable triggers have been eliminated, the next most important step is to make sure headaches are not rebound headaches. Rebound headaches are usually caused by medications that are taken daily. However, any medication that is being more than twice weekly could potentially be causing rebound headaches. Migraine prevention programs are less likely to be successful if a patient continues to take a rebounding medication.

Contents

Preventative Medications

The next step is to choose a migraine prevention treatment. Fortunately there are many choices. Four common medications that doctor agree are well proven and highly effective are Elavil® (amitriptylene), Inderal®, (propranolol) Depakote® (valproic acid), and Topamax® (topiramate). Botox is also used if the patient has chronic migraines. The most important thing to remember is that there are numerous agents that one can try for migraine prevention. It is most likely that at least one of them will work well for you. If the first medication does not reduce the number of headaches you are having then don’t be discouraged, you may just need a higher dose or you can try a different medication. If you are having frequent headaches, please see your neurologist to discuss possible preventative treatments!

Elavil® (amitriptylene)

The primary advantage of Amitriptylene or Elavil® is its affordability, which can be as low as $5 per month. Unfortunately, Elavil can have numerous side effects, including dry mouth, sedation, constipation, and weight gain.

Inderal® (propranolol)

Another well-established preventative medication is propranolol or Inderal®. This medication is fairly well tolerated in most individuals and is relatively inexpensive, with a twice-daily generic form running about $4 per month. It can worsen asthma, cause fatigue, and limit aerobic exercise. It is generally thought of as a “weight-neutral medication” and most patients do not experience weight gain, but all patients should be monitored for possible weight gain.

Topamax® (topiramate)

Topamax was first licensed as an antiepileptic medication. It is the most popular medication currently prescribed for headache prevention. Among the most commonly prescribed medications, it is the only one that is clearly associated with weight loss. The average obese patient can expect to lose about 10% of their body weight over one year. Since obesity is a risk factor for frequent migraines over time, a large number of migraine patients who need preventatives are medically overweight or obese. Unfortunately, topiramate does have side effects. Some side effects are more of a nuisance. Carbonated drinks taste badly while taking this drug and some patients experience tingling around the mouth, finger, or toes. Renal or kidney stones occur about 1% of the time and do not go away without additional therapy when topiramate is discontinued. A small percentage of patients have an altered ability to think on the medication that commonly expressed as a word-finding problem. This returns to normal with reduction or discontinuation of the medication. Finally, there is a very rare condition of acute narrow angle glaucoma that is very painful but again resolves with discontinuation of the medication and specific medical therapy.

Depakote ER® or valproic acid

The last of the most common preventatives is valproic acid. The most convenient form for patients is Depakote ER®, a once daily migraine prevention agent. Depakote ER® can cause birth defects. In addition, valproic acid can cause weight gain and liver enzyme problems. Despite these warnings, the medication is generally well tolerated and can be used quite safely. However, given the issue with birth defects it is most commonly prescribed to males with migraines who are not overweight. Valproic acid is also widely used as an anticonvulsant to prevent seizures.

Botox (onabotulinum)

Botox is FDA approved for the prevention of headaches in patients with chronic migraine. Because it is one of the more expensive therapies for migraine prevention, it is generally used after patients fail other therapies. Because of its cost, a headache diary should be kept to determine whether the treatment is clearly helpful. The headache diary can also serve as an early warning when the medication is wearing off. The data on botulinum toxin type A or Botox® is quite extensive. Despite this, there continues to be a lot of controversy over its use. It does appear to help some patients with frequent migraines but it remains to be seen how best to choose which patients to treat with Botox®. The cost of the medication is also quite substantial.

Other agents used widely for prevention of migraine include:

Effexor XR® (venlafaxine)

Venlafaxine or Effexor XR® is an antidepressant. Doses of 150 mg or more of this medication have been demonstrated to be a rather robust migraine agent. This medication can have side effects of nausea, sexual dysfunction and sometimes will increase blood pressure.

Cymbalta® (duloxetine)

Another selective serotonin and norepinephrine reuptake inhibitor (SSNRI) on the market is duloxetine or Cymbalta®. It is relatively more balanced than Effexor® and therefore is easier to titrate. It does cause the same amount of nausea as Effexor but is associated with less sexual dysfunction and less hypertension. Cymbalta is FDA-approved in depression, anxiety, diabetic neuropathic pain, chronic low back pain, osteoarthritis pain, and fibromyalgia pain. Since a large percentage of chronic migraine sufferers also have depression, the use of Cymbalta® as a first line agent makes sense and is FDA-approved for their depression.

Verapamil, Coenzyme Q10, Botox® and PFO

There are studies demonstrating verapamil to be a good anti-migraine agent although not as robust as the medications previously mentioned. Coenzyme Q10, which is available over the counter, was demonstrated in one small placebo controlled trial to be beneficial.

Patients with migraines have an increased risk patent foramen ovale (PFO), a small channel between the right atria and left atria of the heart. PFOs in migraine patients also tend to be larger. Some data suggest closing this hole or channel lessens the incidence of migraine. The most important thing to remember is that there are numerous agents that one can try for migraine prevention. It is most likely that at least one of them will work well for you. Unfortunately prevention therapies are under utilized, resulting in excessive disability for migraine patients. If you are having frequent headaches, please see your neurologist and ask to be placed on prevention.

Oct. 8, 2002 — If you suffer from migraine headaches, chances are you’re a woman. But it turns out an experimental migraine-fighting treatment also has a side effect appealing to many women — it helps them lose weight.

According to ABCNEWS’ Medical Editor Dr. Tim Johnson, 70 percent of migraine patients are women, possibly because of the effects of estrogen.

But as if the painful headaches weren’t punishment enough, the medications that fight them often have disturbing side effects such as extreme fatigue, dry mouth and weight gain.

Now a new drug called topiramate, also known as Topomax, has been found to not only calm down overactive nerve cells in the brain and help fight migraines. Researchers have also discovered that it can help you lose weight.

In a study of 500 migraine patients using topiramate, Dr. Stephen Silberstein, director of the Jefferson Headache Center at Thomas Jefferson University in Philadelphia, has shown that “in addition to taking away their migraine headaches, on average patients lost almost 4 percent of their body weight.”

One Woman Went from Size 20 to Size 2

This weight-loss bonus was life-altering for 30-year-old Catherine Skinner, who has suffered from migraines ever since college and had gained 85 pounds while taking a variety of anti-migraine drugs.

“Everyday I came home from work, and I just wanted to lay down for about an hour or two and sleep. Every afternoon I really felt like I was going to get sick. I really did not feel like I had the stamina to live through everyday,” said Skinner. “This went on every single day of my life for a couple of years.”

But since she was prescribed topiramate one year ago, Skinnner says the drug not only took away the pain, it took away 90 pounds. She says she went from a size 20 to a size 2.

Researchers who have been testing topiramate are about to present their findings to the Food and Drug Administration, and Silberstein expects it to be approved for migraines by 2003.

The Brain on Estrogen

“Anyone who has ever experienced a migraine will tell you that it’s more than just your typical headache; pulsating pain on one side of the head, vomiting, sensitivity to light and sound. Twenty-eight million Americans suffer from this condition — 70 percent of them are women,” reports Johnson.

But contrary to early beliefs, this gender imbalance is not due to differing personality traits or societal standards, but rather is an unfortunate side effect of that essential female hormone — estrogen.

“The genes that predispose people to developing headaches are probably equally present in men and women, it’s just whether or not they get expressed which has a great deal to do with whether cycling hormones are around,” explains Dr. Elizabeth Loder, director of the Headache Management Program at Spaulding Rehabilitation Hospital in Boston.

In other words, many men and women have the same migraine DNA “switch,” and estrogen seems to act as a helper that turns the switch on.

Although nobody knows for sure exactly how estrogen makes migraines more likely to occur, researchers have found that falling estrogen levels are associated with more frequent headaches. “For example, right before the onset of the natural menstrual period, the week ‘off’ the birth control, and right after childbirth,” says Loder.

While estrogen’s primary role may be in helping orchestrate the female reproductive cycle, this hormone has access to virtually all tissues of the body and can exert widespread effects, particularly on the brain. Estrogen can directly influence nerve cells, alter brain chemicals, and even affect blood vessels inside the head.

Migraine Medications

Several categories of drugs can be used to prevent migraines from occurring; epilepsy drugs like Neurontin and Depakote, blood-pressure regulators such as Inderal, and antidepressants such as Elavil must all be taken on a daily basis to be effective.

“Preventative” treatments like these are usually used only in patients who have frequent or severe migraines that cannot be controlled by “acute” medications, which are used on an as-needed basis to stop a migraine attack once it has begun.

But the preventative medicines for migraines apparently leave much to be desired. They are not as effective as users would like, many have unpleasant side effects, and they can have interactions with other commonly used drugs, cautions Loder.

“You have to make a judgement. Are they frequent enough, severe enough, and long enough lasting to make it worth it to take a preventative medicine every day,” says Dr. Richard Lipton, co-director of The Headache Unit at Montefiore Medical Center in the Bronx, N.Y.

To avoid side effects, many patients are now turning to Botox, a toxin which is injected into the muscles of the head and neck, that has the added advantage of smoothing cosmetic lines and wrinkles. On the down side, Botox can cause temporary facial paralysis and drooping, and the safety of its long-term use is still being investigated.

Fortunately, most migraine sufferers do not need long-term preventative treatments and can use one of the many available “acute” treatments for headaches as they occur.

“Anti-inflammatory drugs like aspirin, Advil, etc., also seem to work for low-grade migraines. For stronger headaches, 80 to 85 percent of patients get significant benefit from the triptan drugs ,” says Loder. “Some patients still use ergotamines, but these have more severe and long lasting side effects. If these all fail, then barbiturates and narcotics are sometimes used as well.”

But Lipton warns that “people should not take acute treatments for more than eight or 10 days a month, because it puts them at risk for developing “rebound” headaches that are brought on by overmedication. You get rebound mainly from overusing narcotics, triptans, etc., but all acute treatments can cause rebound headaches. Even aspirin.”

Migraine Prevention Lifestyle

Many experts agree that the best — although not the easiest — way to prevent headaches is to lead a healthy and headache-prevention lifestyle and avoid migraine triggers whenever possible.

“Hormonal cycling may prime the brain and make migraine more likely to occur, but it is by no means the only trigger for individual attacks in women,” says Loder. “Lack of sleep, altered sleep-wake cycles, and general stress are far more common triggers in patients with migraines.”

To help avoid migraines that are concentrated around the start of the menstrual cycle, experts say that over the counter medications like Aleve and Advil can be used in the short term, perhaps a couple of days before flow begins and through the fist couple of days of flow. Triptans taken on a short term basis can be used to prevent menstrual migraines as well.

For women who are already taking birth control pills, there are some new formulations that decrease the amount of time without estrogen, about two to three days instead of one week, which can help prevent headaches triggered by estrogen withdrawal. Another alternative is to take the pill continuously for two to four months and skip the estrogen-lowering placebo weeks altogether.

However, using birth control to control migraines for women who are not already taking them is not recommended, since there are several risks associated with these medications.

Antidepressants

Some drugs that treat depression, called antidepressants, have been found to be effective in preventing migraine, even in people who do not experience depression.1

There are different types of antidepressants, including tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs) as well as selective serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors (SNRIs). These medicines work by affecting different chemical pathways in the brain.

People with migraine are five times more likely to also suffer from depression and anxiety, so they may benefit especially from using antidepressants as a way to prevent frequent migraine attacks.2 Some antidepressants can also help people who have trouble sleeping, as well.3

How do antidepressants work?

The way antidepressants work to prevent migraine isn’t fully understood. They affect neurotransmitters in the brain, and these may be associated with migraine. They are also effective at blocking pain for a number of conditions, including headache, at lower doses than are needed to prevent depression.2

The evidence of the efficacy of antidepressants for preventing migraine changes over time, as more studies look into prevention. So far, two antidepressant medications have been classified as “probably effective” at preventing migraine. These are amitriptyline (a generic tricyclic antidepressant) and venlafaxine (a generic SNRI).4 Other tricyclics are also sometimes prescribed because they have fewer side effects, but they haven’t been studied as much.1

SSRIs, which are some of the most commonly prescribed medicines for depression, are not effective for migraine prevention.3

What are some common antidepressants that prevent migraine?

Most antidepressants that are used to prevent migraine are available as generics. They can be found in tablets, capsules, and liquid forms.

Common tricyclic antidepressants include:

  • amitriptyline (Elavil® and Vanatrip®)
  • nortriptyline (Aventyl® and Pamelor®)
  • Common serotonin/norepinephrine reuptake inhibitors (SNRIs) include:

  • duloxetine (Cymbalta® and Irenka®)
  • venlafaxine (Effexor®)
  • What are some side effects of antidepressants?

    Side effects are common for people taking antidepressants. However these medicines can be used at lower doses for migraine prevention than for stabilizing mood, and this might reduce the number and severity of side effects for patients. The following is a partial list of side effects associated with antidepressants4:

    • Disturbances in heart rhythm
    • Drowsiness
    • Confusion
    • Dry mouth
    • Painful urination
    • Sexual dysfunction
    • Weight gain
    • Dizziness
    • Blurred vision
    • Lightheadedness
    • Headaches
    • Constipation
    • Insomnia and nervousness

    Some of these symptoms can be more serious in older people, so it’s important to check with your doctor and monitor your health carefully if you are taking antidepressants.4

    Many antidepressants, most notably SSRIs and SNRIs, come with the U.S. Food and Drug Administration’s strongest warning that they are associated with increased risk of suicidal thoughts and behaviors in children, adolescents and young adults taking them for mood disorders.5 Tricyclic antidepressants can be fatal in overdose. If you are taking these medications, you should monitor your mental health and if you experience any changes, notify your doctor immediately.

    What else should I know about antidepressants for migraine?

    Antidepressants can have serious interactions with other drugs. It is important to let your doctor know all other medications you take including oral contraceptives, barbiturates, MAO inhibitors, sleep medicines, antihistamines, painkillers, blood pressure medicines and others.

    Tell your doctor if you have ever had seizures, urinary retention, glaucoma or other chronic eye conditions, a heart or circulatory system disorder, liver problems, or are taking thyroid medication. You should also tell your doctor if you are planning surgery or are pregnant, breastfeeding or may become pregnant before taking an antidepressant.

    Antidepressants can make you drowsy or confused, so you shouldn’t drive, operate heavy machinery, or perform dangerous activities until you know how the medicine will affect you.

    Antidepressants should never be stopped abruptly. First consult your doctor who will advise you on how to gradually cut down your dose.

    Antidepressants have helped millions of people cut through the dark fog of depression. Many others try these medications but stop taking them, often because of side effects such as weight gain. A study from a Harvard-based team shows that the amount gained is usually small, and that it differs little from one antidepressant to another.

    Earlier studies linking antidepressant use to weight gain were usually small and short. This one, led by researchers with Massachusetts General Hospital’s Center for Experimental Drugs and Diagnostics, included more than 19,000 men and women and lasted for a year.

    Using electronic health records, the researchers identified men and women who took an antidepressant for at least three months. Medications used included amitriptyline (Elavil), bupropion (Wellbutrin), citalopram (Celexa), duloxetine (Cymbalta), escitalopram (Lexapro), fluoxetine (Prozac), mirtazapine (Remeron), nortriptyline (Pamelor), paroxetine (Paxil), venlafaxine (Effexor), or sertraline (Zoloft). They also identified another 3,400 people who took some other type of medication for a non-depression ailment. Each person’s weight was checked every three months for a year.

    The researchers chose citalopram as a reference, because earlier studies suggested that it is “average” when it comes to weight gain. In this study, the weight gain experienced by people taking citalopram averaged one to two pounds. Compared to citalopram, the weight gain linked to other antidepressants was small.

    Bupropion was associated with the least amount of weight gain, close to none. Two others that also appeared to have less weight gain were amitriptyline and nortriptyline. Amitriptyline and nortriptyline are older drugs. Because newer drugs tend to have fewer side effects, those two aren’t prescribed as frequently. At the other end of the spectrum, citalopram caused the most weight gain. Even so, the differences between the drugs were small. The results of the study were published in JAMA Psychiatry.

    Not everyone taking antidepressants gained weight. Some actually lost a few pounds.

    Tip for choosing an antidepressant

    The results of this study indicate that worries about weight gain shouldn’t influence the choice of antidepressant for most people. One antidepressant is generally as effective as another. If you need to choose an antidepressant, let cost and potential side effects be your guide.

    Many antidepressants are available as generics. Generics work as well as brand name drugs, but cost less.

    Here are some tips for choosing a treatment based on common side effects:

    • Sexual side effects, such as difficulty having an orgasm. Bupropion may be less likely to cause this side effect. It’s also the one associated with the least amount of weight gain.
    • Sleepiness. Some antidepressants make you sleepy. If you have trouble falling asleep or staying asleep, taking one of these before bed, like trazodone, might be a good idea. Paroxetine is another good choice.
    • Decreased energy level. No antidepressant leads the pack in terms of being more stimulating. Perhaps bupropion or fluoxetine might be a good first choice.

    If you start taking an antidepressant, don’t expect to see a major improvement right away. It often takes 6 to 8 weeks to see a response to an antidepressant. And don’t give up if the first one doesn’t work. Trying a different one may do the trick.

    Another option to consider is psychotherapy, especially if the first drug doesn’t work. People who do not respond to the first antidepressant can often do as well with talk therapy as they would with another drug.

    Keep in mind that a small number of people have a condition called atypical major depression. Instead of the more usual problems of decreased appetite and difficulty sleeping, their depression causes an increased appetite and sleeping too much. This leads to weight gain regardless of drug therapy. For them, it’s probably best to stay away from an antidepressant that causes even more weight gain.

    Pamelor

    SIDE EFFECTS

    Note

    Included in the following list are a few adverse reactions that have not been reported with this specific drug. However, the pharmacologic similarities among the tricyclic antidepressant drugs require that each of the reactions be considered when nortriptyline is administered.

    Cardiovascular

    Hypotension, hypertension, tachycardia, palpitation, myocardial infarction, arrhythmias, heart block, stroke.

    Psychiatric

    Confusional states (especially in the elderly) with hallucinations, disorientation, delusions; anxiety, restlessness, agitation; insomnia, panic, nightmares; hypomania; exacerbation of psychosis.

    Neurologic

    Numbness, tingling, paresthesias of extremities; incoordination, ataxia, tremors; peripheral neuropathy; extrapyramidal symptoms; seizures, alteration in EEG patterns; tinnitus.

    Anticholinergic

    Dry mouth and, rarely, associated sublingual adenitis; blurred vision, disturbance of accommodation, mydriasis; constipation, paralytic ileus; urinary retention, delayed micturition, dilation of the urinary tract.

    Allergic

    Skin rash, petechiae, urticaria, itching, photosensitization (avoid excessive exposure to sunlight); edema (general or of face and tongue), drug fever, cross-sensitivity with other tricyclic drugs.

    Hematologic

    Bone marrow depression, including agranulocytosis; eosinophilia; purpura; thrombocytopenia.

    Gastrointestinal

    Nausea and vomiting, anorexia, epigastric distress, diarrhea, peculiar taste, stomatitis, abdominal cramps, blacktongue.

    Endocrine

    Gynecomastia in the male, breast enlargement and galactorrhea in the female; increased or decreased libido, impotence; testicular swelling; elevation or depression of blood sugar levels; syndrome of inappropriate ADH (antidiuretic hormone) secretion.

    Other

    Jaundice (simulating obstructive), altered liver function; weight gain or loss; perspiration; flushing; urinary frequency, nocturia; drowsiness, dizziness, weakness, fatigue; headache; parotid swelling; alopecia.

    Withdrawal Symptoms

    Though these are not indicative of addiction, abrupt cessation of treatment after prolonged therapy may produce nausea, headache, and malaise.

    Postmarketing Experience

    The following adverse drug reaction has been reported during post-approval use of Pamelor. Because this reaction is reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate frequency.

    Cardiac Disorders – Brugada syndrome

    Eye Disorders – angle-closure glaucoma

    Read the entire FDA prescribing information for Pamelor (Nortriptyline HCl)

    Amitriptyline–preventive treatment of migraine headache?

    Elavil, or now commonly called by the generic name, amitriptyline, came out in 1961 and is one of the oldest drugs used for migraine prevention currently. Although originally intended for treatment of depression by the FDA at doses of 75-150 mg, headache doctors successfully use lower doses such as 10-30 milligrams taken at bedtime.

    This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, and blogger.

    Amitriptyline-preventive treatment of migraine? Yes, the American Academy of Neurology current update for pharmacologic treatment for episodic migraine prevention for adults states that Amitriptyline has “Moderate Evidence” of treatment success and “should be considered for migraine prevention. (Level B).

    Related issues.

    How to dose amitriptyline.

    Psychiatric level treatment of 75-150 mg for depression may have side effects of early morning drowsiness, a dry mouth, constipation, and possible weight gain.

    However, using 10-30 mg of amitriptyline at night for headache doesn’t usually cause weight gain and the side effects are more tolerable.

    Early morning drowsiness may be a limiting side effect. If this occurs, the patient should try starting at one half of 10 mg or 5 mg for a few weeks and then advancing to 10 mg.

    Taking the drug earlier in the evening may also be helpful. That is, if the patient goes sleep at 10:00 they would take amitriptyline at 9 PM.

    Amitriptyline success alone

    Amitriptyline alone, usually given at night, reduces migraine by about 30%.

    Amitriptyline helps with sleep.

    The drug is useful for migraine patients also because they commonly have psychiatric illness such as depression (50% comorbid with migraine) or generalized anxiety disorder (GAD) and panic disorder both of which are 40 % comorbid with migraine.

    Depression and GAD have the common cardinal symptom of insomnia and amitriptyline is the only recommended drug for migraine prevention which really helps with sleep.

    Amitriptyline is not addictive.

    Amitriptyline is a class 2 drug and is not addictive. Class 4 drugs are narcotics like the opioid narcotic hydrocodone which is addictive.

    Amitriptyline works on dopamine receptors to help migraine and also puts patients into deep levels of sleep. Sleep is good for migraine and many migraine patients don’t sleep well.

    Research sleep studies on migraine patients show that they are usually in light sleep (stage 1 or 2 sleep). However, treated with amitriptyline migraine patients may go into deeper stages of sleep such as stage 3 or 4 which is good for headache.

    Sleep has 4 stages, stage 1 being light sleep and stage 4 being deep sleep.

    Amitriptyline helps nighttime migraine.

    My personal medical experience is that amitriptyline is also a useful drug for nocturnal, middle of the night, and early morning “wake up” headaches.

    Early morning wake up headaches are a very common problem with many migraine patients. I encourage them to keep their acute therapy migraine drug, probably a triptan at bedside with a glass of water so they can just roll over, take their medicine, and go back to sleep.

    A dreadful mistake for many migraine patients is to not treat at the onset of their migraine and then have to suffer a disabling migraine all that same day.

    Amitriptyline treats tension-type headache also.

    Amitriptyline has a recommendation for use with tension-type headache at a dose of 75-150 mg. Migraine patients may also have Tension Type Headache which commonly has a physical finding of muscle tenderness of the head when examined by the doctor. Amitriptyline helps with muscle tenderness.

    Amitriptyline is a very inexpensive drug.

    Another good aspect of the drug is that it is very cheap. In Dallas Walmart sells it for $3-4 and I encourage patients to pay cash for it because their co-pay card price for other migraine preventive drugs may be $5-20. Sometimes it is free with certain insurances.

    Aimovig, one of the new CGRP drugs for migraine, costs $540 per month without insurance.

    Amitriptyline is a very small pill.

    I’ve had patients, particularly adolescents, who couldn’t take certain pills and referred to them as “that horse pill.” 10 mg is a very tiny, easy to swallow pill.

    Consider staying on amitriptyline when you start one of the new CGRP drugs.

    Headache doctors started using Aimovig, the first CGRP drug for migraine, in July 2018.

    I personally used a lot of amitriptyline before that time, often with other preventive migraine drugs like Depakote, propranolol, or topiramate, but I have always advised patients to stay on their previous preventive drugs when they start one of the new CGRP drugs. CGRP drugs don’t help sleeping.

    Then, many patients will stay on amitriptyline and their CGRP drug to continue sleeping well.

    This site is owned and operated by Internet School LLC, a limited liability company headquartered in Dallas, Texas, USA. Internet School LLC is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com. Although this site provides information about various medical conditions, the reader is directed to his own treating physician for medical treatment.

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    Britt Talley Daniel MD

    Amitriptyline & Weight Gain: The Reason 50% Discontinue Treatment

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    Amitriptyline (Elavil) is the most popular TCA (tricyclic antidepressant) medication on the market. It is primarily utilized for the treatment of depression, and in other cases, migraine headaches and anxiety disorders. The drug functions primarily by inhibiting the reuptake of the serotonin transporter, which increases extracellular levels of the neurotransmitter serotonin. Although serotonin is primarily responsible for producing its antidepressant effect, the drug also affects other neurotransmitters like norepinephrine to a minor extent.

    Although TCAs are seldom prescribed as a first-line treatment for depression, some individuals actually find that they work better than SSRIs and other new antidepressants. If a person fails to respond to several newer drugs, a psychiatrist will likely prescribe a TCA – and due to the fact that Amitriptyline is the most popular, it’s what most people end up taking. Like all antidepressants, this drug tends to yield side effects, one of which may be unwanted weight gain.

    Amitriptyline and Weight Gain

    Some studies have estimated that 50% of all patients who discontinue treatment with a tricyclic antidepressant (TCA), do so because they’ve experienced excessive weight gain. For this reason, some people may find that Amitriptyline works extremely well for their depression and balancing their mood, but they may not be able to put up with the increase in weight. Let’s face it, gaining weight can (in some cases) override the antidepressant effects of the drug and actually contribute to depression as a result of poor body image.

    How Amitriptyline Causes Weight Gain

    There is an array of research that has been conducted with Amitriptyline to investigate how the drug may cause weight gain. Researchers have long claimed that this medication can alter your hormone levels, cause you to crave sweets/carbohydrates, and increase your appetite. If you gain weight while taking this particular medication, below are some reasons that may help you understand why.

    • Appetite increase: Some studies have determined that Amitriptyline can be administered to individuals suffering from eating disorders like anorexia and effectively boost their appetite. If you have been taking the drug and notice that you’re a lot hungrier than usual, it could be that the drug is making you feel hungrier than normal (for a variety of reasons).
    • Craving carbohydrates: There are multiple studies that have found that those who take Amitriptyline tend to experience an increase in cravings for “sweets” and carbohydrates. It is known that carbohydrates will cause weight gain if they are not properly used and/or eaten in excess. The cravings may stem indirectly from this drug’s effect of raising serotonin levels – a neurotransmitter directly tied to carbohydrates.
    • Depression reduction: Some people who are depressed tend to under-eat, leading to a weight loss. Assuming this drug is working to effectively treat the depression, the person may realize that they should resume normal eating habits. This may lead the person to re-gain the weight that was lost during a depressive episode.
    • Fat storage: The body tends to store fat differently when we are taking certain antidepressant medications compared to during homeostatic functioning. This is due to the fact that medications tend to alter metabolic functions as well as various hormones. When hormone levels are altered, some people have a tendency to pack on extra fat with relative ease.
    • Hormone levels: Perhaps another important clue to weight gain that people experience on Amitriptyline is the change in the level of various hormones, particularly that of “leptin.” This hormone is involved in appetite regulation and hunger. When levels of leptin increase (as caused by the drug), we feel hungrier more often, and are more likely to eat.
    • Motivation reduction: The fact that this medication is known to decrease energy levels in those that take it, this often leads to reduced motivation. When your motivation plummets, you are going to have a much tougher time getting your butt up to exercise as well as plan healthy meals; this leads to weight gain.
    • Sedation: A very common side effect that people experience from Amitriptyline is that of sedation. This is considered one of the most sedating TCA medications, leading people to feel fatigued, sleepy, and tired while taking it. If you feel more tired than usual, you may end up exercising less and sleep more – leading to less calories burned and a slower metabolism.
    • Slow metabolism: It is thought that you may experience a slowed metabolism as a result of many of the other factors on this list. Assuming the drug alters your hormones and makes you feel sedated, those to effects alone may contribute to a slow metabolism. Others speculate that the drug-induced physiological changes result in a slowing of the metabolism – leading to weight gain. If you have maintained the same diet and exercise habits throughout your treatment as you did pre-drug, and gain weight, it could be due to metabolic slowing.
    • Social eating: If the drug is working well to treat your depression and/or anxiety, there’s a chance that you may start to socialize more frequently. Frequent socialization often leads to social eating, or eating out with friends. If you end up eating out more than usual, you’re probably going to end up gaining weight.
    • Taste perception: When depressed, some people claim to have a blunted perception of taste or that food just doesn’t seem to have the same pizzazz. If this medication works well to improve your mood, you may find that your taste also improves, leading you to eat more often (and possibly larger portions), both of which can lead to weight gain.

    Note: It is important to understand that although many of the factors listed above can cause weight gain, they degree to which they affect you is highly individualized. One person may start eating out with friends more often on the drug, while another may simply become tired, lethargic, and unmotivated. Keep in mind that the path to gaining weight on any medication is often subject to individual variation.

    Factors that influence weight gain on Amitriptyline

    There are other influential factors that can determine how much weight gain you experience on Amitriptyline. These include things like: the dosage you take, how long you’ve been medicated, your lifestyle, whether you take other drugs, as well as your genetics.

    1. Dosage

    Studies have shown that even if you are taking low-moderate doses of Amitriptyline, you may still gain weight. That said, if you are concerned about weight, it is always recommended to take the minimal effective dose to treat your depression. The higher the dose you take, the more likely you are to gain weight as well as amplify any existing weight gain you’ve experienced.

    When taking high doses, the drug tends to have more influence over your physiological functioning. With increased influence, its effects on neurotransmitters like serotonin become amplified, but so do its unwanted side effects like weight gain. Some people claim that there is a direct dose-weight relationship associated with Amitriptyline.

    2. Time Span

    How long have you been taking this medication? Those that have been on it for years already have likely adapted to its effects and have (in all likelihood) maxed out their potential weight gain. Those that have been on the drug for a long-term likely have experienced some change in weight as well as BMI throughout their treatment.

    It should also be mentioned that the longer you are on this drug, the more likely you are to have become tolerant, and thus need to increase your dosage (which we know can lead to weight gain). Those that use the drug over a very short-term may not notice as much weight gain simply because the body may not have fully adapted to the drug. Unfortunately many people end up having to discontinue after just a moderate term (6 months to 1 year) because their weight has ballooned.

    3. Lifestyle

    While it may be easy to place complete blame on the Amitriptyline for the weight that you’ve gained, it is also important to evaluate your lifestyle. Take the time to consider whether you practice healthy eating, get enough sleep, minimize your stress, and make exercise a priority. If you aren’t getting any exercise, are highly stressed, and are eating garbage foods – your lifestyle may be more of a contributor to your weight gain than the drug you’re taking. Practice healthy habits so that you know whether it is really the drug causing you to gain weight.

    4. Other drugs

    Also think about whether you are taking any other medications. If you are taking an antipsychotic drug, those are associated with more significant weight gain than Amitriptyline. If you are on an array of different medications, it may be helpful to have a discussion with your doctor about which drugs are most likely causing your weight gain. Also keep in mind that those who don’t gain weight on this drug may be unknowingly offsetting the weight gain if they simultaneously take a stimulant medication and/or drug associated with weight loss.

    5. Genetics

    Another explanation for why you gain weight on this drug and another person doesn’t could be due to genetics. Each person has a unique genetic code and genetic variants that respond to this medication. If your genetics aren’t a good fit for the drug or make you more susceptible to weight gain based on this drug’s mechanism of action, you’re going to have a more difficult time staying slim. Fortunately there are new technologies in the works like GeneSight that analyze your genetic code to predict how you’ll respond to various antidepressants.

    How much weight will you gain on Amitriptyline?

    Unfortunately there is minimal research documenting exactly how much weight people gain while taking Amitriptyline. Some studies that analyze tricyclic antidepressants (including Amitriptyline) have reported that people tend to gain between 1 lbs. and 3 lbs. per month while taking the medication for 6 months. Among those taking TCAs, people tend to gain anywhere from 3 lbs. to 16 lbs. after being medicated for 6 months. Since Amitriptyline is one of the more sedating TCAs on the market, some speculate that more weight gain is common.

    Does Amitriptyline cause everyone to gain weight?

    Not everyone gains weight on Amitriptyline. As was already mentioned, weight gain is highly based upon individual factors such as genetics, lifestyle, and whether you’re taking other medications. That said, most people who are only taking Amitriptyline are likely to experience some weight gain. While it may be discouraging to gain some weight, with adequate exercise and healthy dietary intake, it can be minimized.

    • Source: http://www.ncbi.nlm.nih.gov/pubmed/6238068

    Should you discontinue treatment if you gain weight?

    Up to 50% of all people who discontinue this drug do so because of weight gain. If you are planning on quitting this particular drug, you may want to talk to your doctor about other options. It is important to always weigh the therapeutic benefit you are getting with the unwanted side effects such as weight gain. If the weight you’ve gained has become problematic and impairs your functioning, you may want to consider Amitriptyline withdrawal.

    However, if the drug is working well to keep your major depression under control, you may be able to justify some weight gain. Never be too quick to discontinue a drug just because you’ve packed on a few pounds. Proper interventions such as daily exercise, changing your diet, and possibly other medications may be able to help offset the weight gain; talk to your doctor about what can be done.

    Did you gain weight while taking Amitriptyline?

    If you’ve taken this drug (or are currently taking it) and have experienced weight gain, be sure to talk about it in the comments section below. It may be helpful if you include some specific information such as how long you’ve been taking the drug, when you first noticed the weight gain, your dosage, and other medications. Also mention why you believe the drug caused you to gain weight. Even if you didn’t gain any weight (or are a rare person who lost weight) on this drug, you are welcome to join the discussion.

    • Source: http://www.ncbi.nlm.nih.gov/pubmed/2975806
    • Source: http://www.ncbi.nlm.nih.gov/pubmed/872612

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    The “Skinny” on Obesity and Migraine

    Thank you to Lee Peterlin, DO; Simona Sacco, MD; Andrea Harriott, MD for their contributions to this spotlight.

    Migraine and Obesity

    Migraine and obesity are common conditions that have a major impact on patients, their families, and society. Over the past two decades, scientists have figured out that the chances of having migraine are increased in those who are obese and that this risk increases as someone gains weight and changes physical stature from normal weight to overweight to obese. They’ve also learned that migraine patients who are obese are more likely to develop a chronic attack pattern.

    It’s important to understand that obesity does not cause migraine. Rather, it’s a risk factor, which means being obese makes it more likely you will have migraine. (Age is also a risk factor, but not a cause.) What’s more, doctors consider obesity a modifiable risk factor, one that can be changed (unlike age). So if you have migraine and are obese, think of it as a project that you, your doctors, and your nutritionist can work on together — as a team.

    If you have migraine, knowing your obesity status may make it easier to choose migraine treatments that meet your needs. It can also

    influence which drugs your doctor recommends to help you avoid gaining weight or to help you lose weight. The team approach is similar to patients with high cholesterol, who work on their own and with their doctors on exercise, diet, and medication choices to decrease the risk of heart attack and stroke. With migraine and obesity, the big difference is the ultimate goal: having fewer and less intense attacks.

    What is “Obesity”?

    Obesity means having too much fat tissue. But how much is too much? You might be surprised to learn that accurately measuring body fat can be both challenging and expensive. The good news is that there is a quick and inexpensive way to estimate obesity. It’s called the body mass index or BMI. BMI can be calculated using your height and body weight and applying a mathematical formula. The World Health Organization defines obesity as having a BMI of at least 30 (or at least 23 for people of Asian descent). See chart below.

    Table 1. Obesity Categories Based On The Body Mass Index (BMI)
    Non-Asian Populations Asian Populations⃰
    BMI < 18.5 BMI <18.5 Underweight
    BMI 18.5-24.9 BMI 18.5-22.9 Normal weight
    BMI 25-29.9 BMI 23-24.9 Grade I obesity Overweight
    BMI 30-39.9 BMI 25-30 Grade II Obesity Obese
    BMI ≥ 40 BMI ≥ 30 Grade III Obesity Morbid Obesity
    ⃰In 2000 the World Health Organization, the International Association for the Study of Obesity, and the International Obesity Task Force recommended that the BMI value of ≥23 represent overweight physical status and a BMI of ≥25 represent obesity in Asians. In 2004 the World Health Organization identified potential public health action points for a BMI between 23.0 – 27.5 in Asian populations; however, formal recommendations for obesity status, based on BMI cutoffs, were not made; and the WHO proposed that each country make decisions regarding BMI definitions at increased risk for its population.

    The Link Between Migraine and Obesity

    The link between migraine and obesity has been studied for over 15 years, with more than a dozen studies conducted on patients of all ages and types. Taken as a whole, the evidence says that obesity raises the risk of having migraines as much as 50% — about the same amount as having heart disease or bipolar disorder. But the risk grows as obesity increases, and it’s almost 3-fold (275%) in patients with BMIs above 40.

    Understanding the Relationship

    Since the mid-1990s, experts have come to believe that fat is a highly active substance. In fact, fat tissue secretes a wide range of molecules that send signals to many other body parts and systems. In people who are obese, the extra fat cells tell the body to make inflammatory proteins. This new understanding of fat cells suggests that obesity keeps the body in a mild, but constant, state of inflammation.

    We still don’t fully understand how migraine and body composition are related, but studies are underway. At present, it appears that a region of the brain (the hypothalamus) that controls hunger and neurotransmitters associated with migraine may play a key role. It’s also possible that obese people are more sensitive to stimulation.

    Obesity-Related Proteins

    Several obesity-related proteins are being studied for their role in migraine. Two of the most important are orexin and adipokines.

    With orexin (which is also considered a hormone), studies in animals and humans indicate that it may be involved in many aspects of migraine. But study results have been inconsistent. Researchers, from Harvard University, now think they may have better luck with drugs that have been fine-tuned to work on orexin.

    Adipokines are proteins found in fat cells called adipocytes. A few studies have shown that, in some migraine patients, levels of certain adipokines (e.g., adiponectin, leptin, and resistin) are elevated during and between attacks. An author of this article (BLP) was the first to hypothesize a relationship between any adipokine and migraine. A high-quality scientific review of adipokines and migraine was recently published. Refer to the Further Reading section (below).

    Treatment Considerations

    Check the Label

    If you struggle with your weight and have migraine, talk with your doctor about the effect of your medications on weight. Weight gain is among one the most common reasons for a patient to reject trying and to stop a migraine prophylactic medication — even when it has been effective.

    As this table shows, many of the most common migraine medications can cause weight gain. But some are weight-neutral, and a few may cause weight loss.

    Weight and Migraine Preventative Medications
    Drug Class/drug Weight Change
    Antidepressants
    amitriptyline
    nortriptyline
    protriptyline
    venlafaxine ↔↓
    duloxetine ↔↓
    Anticonvulsants
    divalproex sodium
    gabapentin
    lamotrigine
    topiramate ↓↓
    Beta Blockers
    Calcium Channel Blockers
    flunarizine
    verapamil
    Angiotensin Receptor Blockers
    candesartan
    Serotonin (5HT) antagonists
    methysergide
    cyproheptadine

    Get Moving: The Benefits of Aerobic Exercise

    Exercise and migraines have a strong, two-way relationship. A lack of exercise increases the risk of having migraine attacks by approximately 21% in adults and 50% in adolescents. But regular and consistent aerobic exercise not only reduces the chances of having migraine attacks, it also makes them less painful and disabling when they do occur. Although it’s hard to generalize, those who regularly exercise for about 40 or 50 minutes on 3 days per week seem to enjoy the most benefits.

    Diets for Migraine

    In 1873, Dr. John Fothergill — an English physician, plant collector, philanthropist — was quite certain that “nothing more speedily and effectually give the sick headache ”. But by 1925, other experts were confident he was wrong; the sole cause of migraine was an inability to metabolize protein.

    Physicians have been debating for over a century whether abnormalities in fat or protein metabolism contribute to migraine. They’ve also argued about which diets can help people with migraine. The debate rages on today, at least partially fueled by conflicting findings from research that is not always of the highest quality. But while you can be sure that there’s no such thing as “The Migraine Diet,” some studies are hinting that there may be benefits from low-fat and high-protein diets, not to mention diets high in specific fatty acids.

    Here’s a brief review of what we know so far.

    Low-Fat

    Some evidence suggests that a low-fat diet can be good for people with migraine. In a study comparing a low-fat diet (i.e., less than 20% of total intake) with a standard diet in patients with episodic or chronic migraine, those who ate a low-fat diet had 64% fewer headache days per month after three months. The reduction in headache days for patients on the standard diet was only 8%. More research is needed to validate the use of a low-fat diet in those with migraine.

    High Protein

    Low-carbohydrate (also known as ketogenic) diets generally limit the amount of carbohydrates to fewer than 20 grams per day. Early research in this area was not promising, but at least one study suggests the story is not yet over. In a group of overweight women with migraine, those who had a low-carbohydrate diet had 80% fewer attacks after the first month on the diet. After six months, the number of days with migraine was still 40% lower than it had been when starting the diet. Further research is needed to validate these findings.

    Omega Fatty Acids

    Omega fatty acids may affect the likelihood of having a migraine attack. Early research found that a diet low in omega-3 fatty acids tends to increase the number of attacks. But another study using supplements (i.e., not a diet) was unable to replicate those results. A newer, three-month study of adults with chronic tension-type headache or migraine — this time using a diet high in omega-3 and low in omega-6 fatty acids (think salmon and flaxseed) — found that the diet cut attack frequency by more than half (53%). Based on these encouraging results, it is possible that future research will reveal exciting possibilities in this area.

    If you liked this section, check out the Migraine and Diet Spotlight On article by Drs. Halker, Ailani, and Dougherty. It nicely details and summarizes this data.

    Bariatric Surgery

    Currently, migraine is not an appropriate indication to pursue bariatric surgery. But if you qualify for other reasons and have the procedure, 3 studies suggest that you may end up with fewer and less intense migraine attacks. While these findings are encouraging, more studies are needed to clarify the possible benefits of bariatric surgery in migraine patients.

    Further Reading

    Summary

    In summary, obesity increases the risk of migraine and this risk increases with increasing obesity status from normal weight to overweight to obese to morbidly obese. Several neurotransmitters, proteins, and molecules that participate in maintaining energy appear to be involved in migraine. Aerobic exercise is effective for migraine prevention, and low-fat or ketogenic diets may be effective; while not indicated for migraine alone, bariatric surgery may also be beneficial in reducing attack frequency and severity. Overall, and as for good health in general, it is important for those with migraine to maintain a healthy weight and to maintain healthy lifestyle choices in terms of both diet and exercise.

    Are the new migraine medications working?

    Doctors say three recently approved migraine prevention drugs are helping people have fewer headaches.

    Published: October, 2019

    For people with frequent, debilitating migraine headaches, 2018 brought encouraging news. The FDA approved three new medications — erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality) — the first drugs designed specifically to prevent migraines and reduce their frequency, intensity, and duration.

    It was a big development, since other medications used to stop migraines were created to control other conditions, such as seizures, depression, high blood pressure, or an irregular heartbeat. But their side effects (such as weight gain, dizziness, or fuzzy thinking) often cause people to skip treatment.

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    How to control weight gain when prescribing antidepressants

    SEE THE WEBCAST

    Hear Dr. Schwartz’s strategies for monitoring patients during antidepressant therapy and for motivating them to lose weight. .

    Weight gain occurs with most antidepressants but is frequently overlooked, perhaps because clinicians are focused instead on metabolic effects of antipsychotics and mood stabilizers. Patients taking antidepressants often complain of weight gain, however, and many of the drugs’ FDA-approved package inserts acknowledge this effect.

    Two-thirds of patients with major depression present with weight loss, and gaining weight can be associated with successful treatment. Weight gain is of concern—and likely to be drug-induced—if it exceeds the disease-induced weight loss and continues after depressive symptoms improve.

    Weight may change early or late during antidepressant treatment, and gaining in the first weeks usually predicts future gains.1 Patients who are overweight when treatment begins are especially at risk if given weight-promoting agents. This article:

    • compares antidepressant effects on patient weight
    • discusses mechanisms by which antidepressants may cause weight gain
    • outlines a plan to prevent excess weight gain when patients start antidepressant therapy
    • recommends diet, exercise, cognitive-behavioral therapy (CBT), and medications for overweight patients on long-term antidepressant treatment.

    Weight-gain potential by class

    Unlike antipsychotics, antidepressants have not been associated in clinical trials with causing metabolic syndrome and diabetes. Even so, certain antidepressants can cause clinically significant and perhaps more insidious weight gain when compared with some second-generation antipsychotics (SGAs). For example, SGAs on average may cause 2.3 kg/month weight gain during the first 12 weeks of treatment, and mirtazapine caused 3 kg weight gain in a recent 6-week trial.2,3

    Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) may pose a greater weight-gain risk than newer antidepressants, but selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been clinically noted to cause weight gain over time (Table 1).4-16

    SSRIs. Weight gain associated with long-term SSRI use seems clinically apparent, but the evidence is preliminary.

    Paroxetine seems to be the SSRI most likely to cause weight gain. A 26- to 32-week comparison trial by Fava et al10 showed that weight gain risk with SSRI therapy varies with the drug used. In this trial, 284 patients with major depressive disorder were randomly assigned to double-blind treatment with paroxetine, sertraline, or fluoxetine:

    • More of those taking paroxetine gained >7% in weight from baseline, and their weight gain was statistically significant.
    • Sertraline-treated patients had modest, nonsignificant weight gain.
    • Fluoxetine-treated patients had modest, nonsignificant weight loss.

    Using paroxetine with an antipsychotic can be especially problematic. Fukowi and Murai17 described 2 cases in which adding paroxetine to risperidone caused severe weight gain (13.5 kg to >14 kg) in 4 to 5 months.

    Citalopram may cause a 1- to 1.5-kg weight gain over 1 year,8 whereas fluvoxamine has been shown not to affect weight in obese patients.11 Citalopram (like TCAs) can cause carbohydrate craving and early weight gain.18 Escitalopram caused a modest (0.5 kg) weight gain in elderly patients during an 8-week trial.13

    Initial weight loss followed by overall weight gain after 1 year of SSRI treatment is a common clinical finding that was not noted in initial acute SSRI drug trials. In a comparison of fluoxetine’s acute and long-term effects,19 839 patients experiencing a major depressive episode were first treated with open-label fluoxetine, 20 mg/d. After 12 weeks, 395 patients who met criteria for remission were randomly assigned to continue with placebo or fluoxetine, 20 mg/d, for 14, 38, or 50 weeks.

    In the acute phase, a small but statistically significant weight loss (mean 0.35 kg, P

    • 1.1 kg at 26 weeks (P
    • 2.2 kg at 38 weeks (P
    • 3.1 kg at 50 weeks (P

    The authors concluded that the weight gain—similar with fluoxetine or placebo—was probably associated with recovery from depression rather than fluoxetine treatment, although this was not a controlled variable in the study.

    Table 1

    Long-term effects of antidepressants on body weight, by class*

    Class Effect (gain, loss, or neutral)
    MAOIs Moderate gain overall
    Phenelzine: greatest gain in MAOI class
    Transdermal selegiline: appears neutral
    Novel antidepressants Bupropion: weight loss4
    Mirtazapine: greatest potential for gain among antidepressants5
    Nefazodone: neutral6
    Trazodone: modest gain7
    SSRIs Citalopram: modest gain8
    Escitalopram: modest gain9
    Fluoxetine: modest loss acutely10
    Fluvoxamine: neutral11
    Paroxetine: greatest gain in SSRI class10
    Sertraline: modest gain10
    SNRIs Duloxetine: modest gain12
    Venlafaxine: modest gain (controversial)13
    TCAs Amitriptyline: gain14
    Imipramine: gain15
    Nortriptyline: neutral16
    * Information is a general representation of available literature, gathered from many studies with differing designs. Consult original reports for specific data on dosing, patient populations, treatment durations, and weigh changes.
    MAOIs: monoamine oxidase inhibitors; SNRIs: serotonin-norepinephrine reuptake inhibitors; SSRIs: selective serotonin reuptake inhibitors; TCAs: tricyclic antidepressants

    You Will Gain Weight on these 6 Psychiatric Medications

    I had been on the drug Zyprexa (olanzapine) for four weeks and had already gained 15 pounds which, you know, didn’t help my depression.

    After going to a wedding and catching a side view of myself, I called my doctor and told him that my name was now Violet Beauregarde, you know, the gum chewer in “Charlie and the Chocolate Factory” who becomes a blueberry balloon. Except that when I rose to the top of the room I was crying.

    “The two most common questions that patients ask me are, ‘Will I become dependent on the medications?’ and ‘Will I gain weight?’” says Sanjay Gupta, M.D.

    It’s a serious concern for people considering taking any kind of psychiatric medicine, and a sensitive subject among patients who are currently on meds. “A rapidly expanding waistline is one of the major reasons why patients prematurely discontinue an otherwise effective treatment, fall back into depression, and experience a poor outcome,” says Gupta.

    He ranks various drugs for weight-gain potential and comes up with these six (in order of waist busters):

    A few important points:

    • Clozaril, Seroquel, and Zyprexa are antipsychotic medications that increase insulin resistance, and therefore lead to weight gain.
    • Remeron is an alpha-2 receptor blocker, an antidepressant that is sometimes administered to people — emaciated folks — who need to gain weight. One set of studies indicated that most patients gain weight on Remeron after the first four weeks of treatment.
    • Depakote is an acidic chemical compound used as an anticonvulsant and mood-stabilizing drug to treat bipolar disorder.
    • Paxil is an SSRI more likely than any other SSRI to put on pounds, especially when used for a year or longer. One study indicated that 25 percent of Paxil users gained some serious weight compared with seven percent of Prozac users and four percent of Zoloft users.
    • Among the older antidepressants, the tricyclics such as Sinequan (doxepin), Tofranil (imipramine), and Pamelor (nortriptyline) can cause short- and long-term weight gain.
    • Monoamine oxidase inhibitors (MAOIs) such as Nardil (phenelzine), Parnate (tranylcypromine), and Marplan (isocarboxazid) may also necessitate a new wardrobe.

    That’s the bad news. And boy, is it bad news. Have a weight loss or weight maintenance plan ready to go.

    The good news is these drugs are peculiar. A compound that makes my sister’s pants split doesn’t do anything to me. And what makes me shriek at a side view in the mirror is easy on her metabolism. Even though we’re twins.

    So it’s just a painful trial and error — like everything in recovery — until you find the right drug that will help you function through the day and allow you to pull on your jeans up without help.

    Originally posted on Sanity Break at Everyday Health.

    Image courtesy of MedicalNewsToday.com

    You Will Gain Weight on these 6 Psychiatric Medications

    Common Anti-Depressants Do Cause Weight Gain

    Psychiatrists can’t tell you for sure if an antidepressant will make you gain weight; people vary. But the common prescriptions are associated with weight gain, with small variations among them. Wellbutrin (bupropion hydrochloride) do slightly better than the pack.

    A 2014 study confirmed this when researchers looked at data in electronic records for 22, 610 adults who received a new prescription and were weighed in a doctor’s office every three months over a year. The study participants were taking popular drugs—besides Wellbutrin, Prozac (fluoxetine hydrochloride), Celexa (citalopram hydrobromide), Cymbalta (duloxetine hydrochloride), Lexapro (escitalopram oxalate), Remeron (mirtazapine), Paxil (paroxetine hydrochloride), Effexor (venlafaxine hydrochloride) and Zoloft (sertraline hydrochloride). They were also taking two that are less well known: Elavil ( amitriptyline hydrochloride) and Pamelor (nortriptyline hydrochloride). The researchers compared the rate of weight gain for each drug against the weight gain among patients taking Celexa (citalopram).

    It turned out that people taking Wellbutrin, Elavil and Pamelor gained less weight than those taking the other drugs. So why aren’t Elavil and Pamelor more popular? Both belong to a family of drugs called tricyclics that is older than the currently popular drugs and tend to cause more side-effects other than weight gain. Wellbutrin is also different from the others. It affects the brain chemicals norepinephrine and dopamine rather than serotonin, which is targeted by “SSRIs” and “SNRIs” (the “n” stands for norepinephrine). Wellbutrin has side-effects, too.

    Is fear of weight gain a reason not to take anti-depressants? Every medical choice involves weighing the pluses and negatives. The evidence for anti-depressants is quite weak. That said, weight shouldn’t be your main concern. When you’ve been down for too long, it’s hard not to assume the worst—that you’ll balloon and still feel lousy. If your prescription works, when the cloud lifts, you can decide how important it is to you to keep your weight down. You may still gain because of the medication, but not so much. Maybe you’ll have more energy to exercise and cook healthy meals. Maybe you’ll be able to resist late-night binges on ice-cream. Or you may get more sleep, which will help shift your body’s metabolism for the better: Too little sleep is a big risk factor for obesity. All of the weight-avoidance strategies mentioned here are good for your mood and overall health, too.

    You can also look for ways to boost your mood so that you need a smaller dose of an antidepressant or can take it for a shorter period of time and possibly minimize weight gain. Try a sunlamp if you feel lowest in the winter, or make sure you get more time outdoors. Consider acupuncture—some science suggests that it can enhance the effect of an antidepressant. Evaluate your diet, level of exercise, relationships, work satisfaction and community ties. Decide whether a psychotherapist could help you see better ways to cope and correct your mental biases.

    Antidepressants are often prescribed for “generalized anxiety disorder”—when everyday events cause bothersome worry. Cognitive behavioral therapy, in particular, has some scientific backing for treating chronic worriers, for example, if the idea of gaining weight is taking over your thoughts.

    An Electronic Health Records Study of Long-Term Weight Gain Following Antidepressant Use

    JAMA Psychiatry. 2014;71(8):889-896. doi:10.1001/jamapsychiatry.2014.414.

    A version of this story also appeared on YourCareEverywhere.

    Nortriptyline and weight loss

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