March 2010

Treating Persistent Insomnia: Therapy, Meds, or Both?
While cognitive behavioral therapy is probably best for long-term treatment of chronic insomnia, hypnotics can add benefits acutely.

Diet and Depression
Overall dietary pattern may be more important than individual components (such as omega-3 fatty acids) in lowering the risk of depression.

In Brief
Another Negative Trial of Ginkgo biloba for Cognitive Decline; Physical Activity during Pregnancy Has Mixed Results on Postpartum Depression

Carotidynia Associated with SSRIs
Carotidynia may be a rare side effect of selective serotonin reuptake inhibitors and might be more common in migraine sufferers.

Clozapine Hypersalivation: A Negative Study with Ipratropium
In a small, double-blind trial, ipratropium (Atrovent and others) was not effective in decreasing sialorrhea associated with clozapine (Clozaril and others) treatment.

Carotidynia Associated with SSRIs

March 2010

Carotidynia is a focal cervical pain that follows the path of an affected carotid artery. It often radiates to the ipsilateral side of the face or ear. Carotidynia is usually attributed to migraine or a viral infection but more rarely may be caused by arterial inflammation, vascular pathology, or arterial occlusion. Jabre et al describe what they believe to be the first case of a patient who developed carotidynia secondary to treatment with two selective serotonin reuptake inhibitors (SSRIs).1

A 43-year-old man had a history of severe migraine headaches and depression (a common comorbidity). On treatment with fluoxetine (Prozac and others), 20 mg daily for 5 months, both migraine and depression improved. However, the patient gradually began to experience left intercostal pain. The pain soon progressed to become bilateral, more constant, exacerbated by deep breathing and movement of the trunk, and distressing. On his own, the patient increased his dose of fluoxetine to 40 mg daily. Two weeks later, he had a tender swollen mass at the right carotid bifurcation and severe pulsating pain radiating to the ipsilateral jaw upon contralateral movement of his head. Imaging studies showed abnormal soft tissue thickening of the patient's right common carotid and its bifurcation, consistent with a diagnosis of carotidynia. Doctors stopped fluoxetine, and within 2 weeks, his symptoms of carotidynia and intercostal pain resolved completely.

Two months later, the patient agreed to be rechallenged with fluoxetine. After 4 weeks of treatment with 20 mg/day, cervical and intercostal pain returned. The pain reversed when fluoxetine was stopped. The patient was rechallenged a third time with fluoxetine with similar time course and results.

Physicians then prescribed citalopram (Celexa), 10 mg daily. Six weeks later, bilateral intercostal pain recurred. Citalopram was stopped, and the pain abated. A rechallenge with citalopram resulted in a recurrence of the pain, which again resolved upon citalopram's withdrawal. Subsequent treatment with amitriptyline (Elavil and others), 25 mg/day, and valproic acid (Depakote and others), 400 mg/day, reduced headache and did not cause more pain.

Carotidynia appears histologically as a perivascular inflammatory reaction. Fluoxetine has been associated with pulmonary inflammation. The authors opine that an SSRI-induced increase in serotonergic neurotransmission could interfere with immune cell activity. This might alter synthesis and production of inflammatory cytokines, which could cause acute intercostal pain and carotidynia.

This probable side effect is serious but must be rare. Conceivably, patients suffering from migraine may be at greater risk.

1Jabre MG, Shahidi GA, Bejjani BP: Probable fluoxetine-induced carotidynia. Lancet 2009;374:1061-1062.