Headache as a presenting feature in patients with serotonin syndrome: A case series

Cephalalgia ◽  
2013 ◽  
Vol 34 (2) ◽  
pp. 148-153 ◽  
Author(s):  
Sanjay Prakash ◽  
Pooja Belani ◽  
Aditi Trivedi
Keyword(s):  
Clinical Features ◽  
Serotonin Syndrome ◽  
Medication Overuse Headache ◽  
Case Series ◽  
Headache Disorders ◽  
Drug Induced ◽  
Positive Effects ◽  
Life Threatening ◽  
Serotonergic Drugs ◽  
Acute Headache

Introduction Serotonin syndrome (SS) is a drug-induced constellation of various clinical features that result from excess central serotonergic tone. The clinical features range from barely perceptible to life-threatening conditions. Cases We describe four patients with acute headache (four days to three weeks) who were receiving serotonergic drugs for other indications. There was a temporal relation between the administration of the serotonergic drugs and the development of the headaches. All four patients fulfilled the Hunter Serotonin Toxicity Criteria for SS. In parallel, two patients fulfilled the Sternbach’s criteria for SS. Discontinuation of the serotonergic drugs and the administration of cyprohepatadine led to complete improvement in three to seven days in all four patients. Discussion A review of the literature suggests that some overlaps exist in the pathophysiology between SS and headache disorders, including medication-overuse headache. The overlap is also in the management. The drugs found to be effective in SS (cyproheptadine, chlorpromazine, olanzapine, etc.) are also known to have positive effects on some headache disorders. Conclusion Physicians should consider the diagnosis of SS in patients with new onset or worsening headache after the addition of serotonergic drugs, especially in the presence of objective signs on examination suggestive of the disorder such as tremor, fever, hyperreflexia, diaphoresis or tachycardia.

scholarly journals Serotonin Syndrome: Pathophysiology, Clinical Features, Management, and Potential Future Directions

2019 ◽  
Vol 12 ◽  
pp. 117864691987392 ◽  
Author(s):  
William J Scotton ◽  
Lisa J Hill ◽  
Adrian C Williams ◽  
Nicholas M Barnes
Keyword(s):  
Serotonin Syndrome ◽  
Tryptophan Hydroxylase ◽  
Monoamine Oxidase Inhibitor ◽  
Receptor Activation ◽  
Clinical Findings ◽  
Oxidase Inhibitor ◽  
Health Concern ◽  
Drug Induced ◽  
Life Threatening ◽  
Serotonergic Drugs

Serotonin syndrome (SS) (also referred to as serotonin toxicity) is a potentially life-threatening drug-induced toxidrome associated with increased serotonergic activity in both the peripheral (PNS) and central nervous systems (CNS). It is characterised by a dose-relevant spectrum of clinical findings related to the level of free serotonin (5-hydroxytryptamine [5-HT]), or 5-HT receptor activation (predominantly the 5-HT1A and 5-HT2A subtypes), which include neuromuscular abnormalities, autonomic hyperactivity, and mental state changes. Severe SS is only usually precipitated by the simultaneous initiation of 2 or more serotonergic drugs, but the syndrome can also occur after the initiation of a single serotonergic drug in a susceptible individual, the addition of a second or third agent to long-standing doses of a maintenance serotonergic drug, or after an overdose. The combination of a monoamine oxidase inhibitor (MAOI), in particular MAO-A inhibitors that preferentially inhibit the metabolism of 5-HT, with serotonergic drugs is especially dangerous, and may lead to the most severe form of the syndrome, and occasionally death. This review describes our current understanding of the pathophysiology, clinical presentation and management of SS, and summarises some of the drugs and interactions that may precipitate the condition. We also discuss the newer novel psychoactive substances (NPSs), a growing public health concern due to their increased availability and use, and their potential risk to evoke the syndrome. Finally, we discuss whether the inhibition of tryptophan hydroxylase (TPH), in particular the neuronal isoform (TPH2), may provide an opportunity to pharmacologically target central 5-HT synthesis, and so develop new treatments for severe, life-threatening SS.

scholarly journals Clinical Features of Liver Injury Induced by Immune Checkpoint Inhibitors in Japanese Patients

2019 ◽  
Vol 2019 ◽  
pp. 1-12 ◽  
Author(s):  
Koji Imoto ◽  
Motoyuki Kohjima ◽  
Tomonobu Hioki ◽  
Tomoyuki Kurashige ◽  
Miho Kurokawa ◽  
...  
Keyword(s):  
Liver Injury ◽  
Liver Biopsy ◽  
Clinical Features ◽  
Immune Checkpoint ◽  
Immune Checkpoint Inhibitors ◽  
Checkpoint Inhibitors ◽  
Case Series ◽  
Japanese Patients ◽  
Malignant Neoplasms ◽  
Drug Induced

Aim. Immune checkpoint inhibitors (ICIs) have improved the survival rate of patients carrying various malignant neoplasms. Despite their efficacy, ICIs occasionally induce liver injury as an immune-related adverse event (irAE). This study aimed to reveal the clinical features of the hepatic irAE in Japanese patients. Methods. Among 387 patients treated with ICIs, those who developed drug-induced liver injury were investigated. We also describe the histological findings and clinical courses of four patients with hepatic irAE who underwent liver biopsy. Results. Among the 56 patients with all-grade liver injury, only 11 (19.6%) showed hepatocellular-type liver injury, which resembled autoimmune hepatitis. Thirty-four patients (60.7%) developed cholestatic or mixed-type liver injury, although only one patient showed abnormal image findings in the bile duct. Most patients with grade ≤2 liver injury improved spontaneously, while two patients with biliary dysfunction required ursodeoxycholic acid or prednisolone. Among eight patients with grade ≥3 liver injury, three required no immunosuppressants and five were treated with prednisolone (three of five patients required other types of immunosuppressants). Four patients in the case series showed diverse clinical features in terms of hepatotoxic pattern, symptoms, and the interval time between the initiation of immunotherapy and the onset of the hepatic irAE. Conclusions. Our findings suggest that ICIs could cause microscopic biliary disorder without any abnormal image finding. Because the hepatic irAE presents diverse clinical features, liver biopsy is recommended to provide appropriate treatments.

Movement Disorders Emergencies

2019 ◽  
Vol 39 (01) ◽  
pp. 125-136 ◽  
Author(s):  
Suraj Rajan ◽  
Bonnie Kaas ◽  
Emile Moukheiber
Keyword(s):  
Movement Disorders ◽  
Serotonin Syndrome ◽  
Clinical Presentation ◽  
Treatment Modalities ◽  
Drug Induced ◽  
Status Dystonicus ◽  
Life Threatening ◽  
At Risk Populations ◽  
Clinical Phenomenology ◽  
Malignant Catatonia

AbstractMany acute and potentially life-threatening medical conditions have hyperkinetic or hypokinetic movement disorders as their hallmark. Here we review the clinical phenomenology, and diagnostic principles of neuroleptic malignant syndrome, malignant catatonia, serotonin syndrome, Parkinsonism hyperpyrexia, acute parkinsonism, acute chorea-ballism, drug-induced dystonia, and status dystonicus. In the absence of definitive lab tests and imaging, only a high index of clinical suspicion, awareness of at-risk populations, and variations in clinical presentation can help with diagnosis. We also discuss the principles of management and rationale behind treatment modalities in the light of more recent evidence.

Linezolid-Associated Serotonin Syndrome

2015 ◽  
Vol 105 (3) ◽  
pp. 244-248 ◽  
Author(s):  
Robert G. Frykberg ◽  
Scott Gordon ◽  
Edward Tierney ◽  
Jaminelli Banks
Keyword(s):  
Serotonin Syndrome ◽  
Monoamine Oxidase Inhibitor ◽  
Case Series ◽  
Oxidase Inhibitor ◽  
Serotonin Release ◽  
Diabetic Foot Infections ◽  
Complicated Skin ◽  
Antibiotic Drug ◽  
Threatening Condition ◽  
Life Threatening

Linezolid, a mild monoamine oxidase inhibitor, is a commonly used antibiotic drug for the treatment of complicated skin and skin structure infections, including diabetic foot infections. Use of linezolid has been associated with serotonin syndrome, a potentially life-threatening condition typically caused by the combination of two or more medications with serotonergic properties, due to increased serotonin release. The goals of this article are to highlight the risk factors associated with the development of serotonin syndrome related to the use of linezolid and to aid in its prevention and early diagnosis. In this case series we report on two hospitalized patients who, while being treated with linezolid for pedal infections, developed serotonin syndrome. Both individuals were also undergoing treatment with at least one serotonergic agent for depression and had received this medication within 2 weeks of starting the antibiotic drug therapy. In these individuals, we noted agitation, confusion, tremors, and tachycardia within a few days of initiation of linezolid therapy. Owing to the risk of serotonin toxicity, care should be taken when prescribing linezolid in conjunction with any other serotonergic agent. Although serotonin syndrome is an infrequent complication, it can be potentially life threatening. Therefore, risks and benefits of therapy should be weighed before use.

scholarly journals Clinical features of medication overuse headache following overuse of different acute symptomatic medications: A preliminary study

2021 ◽  
Author(s):  
Sun-Young Oh ◽  
Jin-Ju Kang ◽  
Hong-Kyun Park ◽  
Soo-Jin Cho ◽  
Min Kyung Chu
Keyword(s):  
Clinical Features ◽  
Clinical Characteristics ◽  
Medication Overuse ◽  
International Headache Society ◽  
Medication Overuse Headache ◽  
Observation Study ◽  
Cross Sectional ◽  
Daily Headache ◽  
Multiple Drugs ◽  
Acute Headache

Abstract Background Medication overuse headache (MOH) is a growing problem worldwide and is defined as daily or near-daily headache in patients with a primary headache disorder who overuse acute medications. There is debate about whether there are differences in the clinical features and risks of MOH induced by different drugs. Here we investigated the clinical characteristics of patients with MOH following overuse of different acute headache drugs such as triptans and other medications.Methods A multicenter cross-sectional observation study, REgistry for Load and Management of MEdicAtion OveruSE Headache (RELEASE), prospectively collected demographic and clinical data from 114 consecutive patients with MOH according to the International Headache Society criteria between May 2020 and January 2021. We calculated the mean duration until onset of MOH from chronic daily headache (MDMOH), mean monthly frequency of severe headache (MMFSH), mean monthly frequency of seeking medical services (MMFMedS), and mean monthly intake frequency (MMIF) as well as headache impact and neuropsychological tests in patients with MOH after overuse of acute headache drugs.Results A total of 105 eligible MOH patients was included in this study. The patients showed overuse of triptans (31/105, 29.5%), ergotamines (8/105, 7.6%), simple or combination analgesics (37/105, 35.2%), opioids (1/105, 0.9%), and combination of two of more drugs (28/105, 26.7%). The MDMOH was significantly longer for the analgesics group (10.6 years) than the ergotamines (4.1 years), triptans (4.3 years), or multiple drugs group (4.8 years) (p = 0.011, Kruskal–Wallis test). The MMFMedS was lower for the analgesics group (0.37 days per month) than the multiple drugs (0.85 days) or triptans (0.58 days) group (p = 0.008, Kruskal–Wallis test). The MMFSH was significantly lower in the triptans group (7.4 days per month) than in the analgesics (14.4 days) or multiple drugs group (13.7 days) (p = 0.005, Kruskal–Wallis test). The MMIF was higher in the multiple drugs group (25 days per month) than the triptans (18.1 days) or analgesics (19.5 days) group (p = 0.007, Kruskal–Wallis test).Conclusion Data from this prospective multicenter study suggest that the clinical characteristics of MOH depend on the type of overused symptomatic headache medications.

scholarly journals Serotonin Toxicity: Implications for Clinical Practice

2016 ◽  
Vol 13 (3) ◽  
Author(s):  
Auston Rotheram ◽  
Wayne Harris ◽  
Colin Curtain ◽  
David Nihill
Keyword(s):  
Adverse Reaction ◽  
Prescription Drugs ◽  
Serotonin Syndrome ◽  
Management Strategies ◽  
Clinical Information ◽  
Over The Counter ◽  
Life Threatening ◽  
Serotonergic Drugs ◽  
High Index Of Suspicion ◽  
Serotonin Toxicity

Serotonin toxicity, or serotonin syndrome, is a potentially life threatening adverse reaction to the use of one or more serotonergic drugs. Patients presenting with low level obscure symptoms may have pathophysiology rooted in adverse dopamine and serotonergic poly-pharmacy reactions involving illegal, over-the-counter and/or prescription drugs. In this clinical information paper an overview of serotonin toxicity, diagnostic criteria, and management strategies will be offered. Cultivating a high index of suspicion for serotonin toxicity across a broad patient demographic is recommended

Adverse drug reactions in anaesthesia

2017 ◽  
Author(s):  
Philip M. Hopkins
Keyword(s):  
Malignant Hyperthermia ◽  
Adverse Drug Reactions ◽  
Serotonin Syndrome ◽  
Plasma Cholinesterase ◽  
Drug Reactions ◽  
Drug Induced ◽  
Perioperative Morbidity ◽  
Acute Porphyrias ◽  
Serotonergic Drugs ◽  
Patients Experience

Adverse drug reactions are implicated in more than 40% of anaesthesia-related deaths. Undoubtedly, many more patients experience morbidity from adverse drug reactions. Widely cited definitions of adverse drug reactions encompass common side-effects but this chapter focuses on those that are unexpected reactions to drugs administered by anaesthetists and that occur at normal drug doses. The chapter includes a comprehensive account of malignant hyperthermia, which remains a major contributor to anaesthesia related to deaths. Malignant hyperthermia is a pharmacogenetic condition triggered by potent inhalational anaesthetics and possibly also suxamethonium. The genetic basis, pathophysiology, clinical presentations, and management of malignant hyperthermia are discussed. The chapter covers two other pharmacogenetic conditions: the acute porphyrias and butyrylcholinesterase (plasma cholinesterase) deficiency. Drug-induced anaphylaxis is another cause of perioperative morbidity and mortality. Recent data indicate that anaphylaxis during anaesthesia may be much more common than previously thought. The other type of adverse drug reaction covered in the chapter is serotonin syndrome. Perioperative serotonin syndrome is most likely to occur when patients who are already taking serotonergic drugs, such as selective serotonin reuptake inhibitor antidepressants or ‘triptan’ antimigraine treatments, are given a second drug with serotonergic properties, such as tramadol.

Drug-Induced Serotonin Syndrome

2017 ◽  
Vol 37 (1) ◽  
pp. 49-54 ◽  
Author(s):  
Dana Bartlett
Keyword(s):  
Monoamine Oxidase ◽  
Serotonin Receptor ◽  
Selective Serotonin Reuptake Inhibitors ◽  
Serotonin Syndrome ◽  
Serotonin Metabolism ◽  
Drug Induced ◽  
Confirmatory Tests ◽  
Life Threatening ◽  
Serotonin Receptor Agonists ◽  
Norepinephrine Reuptake

Serotonin syndrome is a potentially fatal condition caused by drugs that affect serotonin metabolism or act as serotonin receptor agonists. Monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors are the medications most commonly associated with serotonin syndrome. Serotonin syndrome can be mild and of short duration, but a prolonged course, life-threatening complications, and death are possible. Detection of serotonin syndrome is not difficult if the diagnostic criteria are understood and properly used, but the syndrome has no confirmatory tests and other drug-induced syndromes can, to a degree, mimic serotonin syndrome. The treatment is symptomatic and supportive. Antidotal therapies are available, but the evidence for their effectiveness is limited. If serotonin syndrome is promptly identified and aggressively treated, the patient should fully recover.

scholarly journals A case series of cefixime induced Steven’s Johnson Syndrome

2018 ◽  
Vol 7 (8) ◽  
pp. 1648
Author(s):  
Arikeri Vasu Deva Rao ◽  
Imran Khan ◽  
Srinivas Velupula ◽  
Jayababu N. ◽  
Samarasimha Reddy L. ◽  
...  
Keyword(s):  
Case Series ◽  
Stevens Johnson Syndrome ◽  
Allergic Reactions ◽  
Drug Induced ◽  
Major Health Problem ◽  
Johnson Syndrome ◽  
Eye Problems ◽  
Patient State ◽  
Life Threatening ◽  
Hyper Sensitivity

Drug induced adverse reactions are a major health problem. Drug hyper sensitivity reactions manifest themselves in many diseases, of which some are very severe. The most common allergic reactions occur in the skin. Stevens-Johnson syndrome is mainly caused by drugs (antimicrobials e.g.: penicillin’s, sulphonamides and cephalosporin’s e.g.: cefixime, antiepileptic’s, NSAIDS), infections and also by other risk factors not yet identified. The most common allergic reactions occur in the skin. These reactions ranging from simple pruritic eruptions to potentially life threatening events are a significant cause of iatrogenic morbidity and mortality. Identification of the cause, withdrawal of the trigger and supportive management is crucial to improve the patient state. Despite of all therapeutic efforts, mortality is high and increases with disease severity, patient’s age and underlying medical conditions. Survivors may suffer from long-term squeal such as strictures of mucous membranes including severe eye problems.

scholarly journals Tramadol, Pharmacology, Side Effects, and Serotonin Syndrome: A Review

2015 ◽  
Vol 18;4 (4;18) ◽  
pp. 395-400
Author(s):  
Alan David Kaye
Keyword(s):  
Side Effects ◽  
Drug Interactions ◽  
Serotonin Syndrome ◽  
Potential Side Effect ◽  
Serotonergic Activity ◽  
Potential Abuse ◽  
Life Threatening ◽  
The Central Nervous System ◽  
Physician Reviews ◽  
Serotonergic Drugs

Background: Serotonin syndrome is a mild to potentially life-threatening syndrome associated with excessive serotonergic activity within the central nervous system. Serotonin syndrome is associated with medication use, drug interactions, and overdose. While serotonin syndrome is often associated with the use of selective serotonin inhibitors (SSRI), an increasing number of reports are being presented involving the use of tramadol. Methods: This review article contains an overview of serotonin syndrome while specifically looking at tramadol’s pharmacology and risk factors for serotonin syndrome. With tramadol’s increasing popularity, the goal of this article is to make physicians more alert and aware of this potential side effect associated with tramadol. Conclusions: In conclusion, with the increasing incidence of serotonin syndrome, prescribing physicians should be aware of and educate their patients on the potential side effects of tramadol. It is important that the prescribing physician reviews patient medications for concurrent serotonergic drugs and monitors for potential abuse. Key words: Tramadol, serotonin syndrome, drug interactions, analgesics

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