100 Migraine Drugs, A to Z: milnacipran

Milnacipran (Savella) is a drug that is approved by the FDA for the treatment of fibromyalgia. Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and tenderness in localized areas.

Milnacipran belongs to the category of selective serotonin and norepinephrine reuptake inhibitors (SNRIs), which are used to treat anxiety, depression, and pain. There are four other SNRIs that are approved for the treatment of anxiety and depression, and in case of duloxetine (Cymbalta) also for fibromyalgia, peripheral nerve damage due to diabetes and musculoskeletal pain.

The manufacturer of milnacipran decided not to seek approval for the treatment of depression to avoid the stigma of being an antidepressant drug. Many patients feel that if they are prescribed an antidepressant, their pain is not perceived as real physical pain, but rather purely psychological.

Milnacipran was tested for the preventive treatment of migraines only in one unblinded observational study. Not surprisingly, it was effective. We often use duloxetine and venlafaxine (Effexor) for the treatment of migraines. Fibromyalgia, back pain, and other pains are comorbid with migraines, meaning that if you have one condition, you are more likely to have the other as well. Such patients are ideal candidates for SNRIs, although tricyclic antidepressants such as amitriptyline also work well for any pain and migraines.

Just like with other SNRIs, the most common side effects include nausea, headache, constipation, dizziness, insomnia, hot flushes, hyperhidrosis (excessive sweating), vomiting, palpitations, increased heart rate, dry mouth, and hypertension. Another common problem with these drugs is that many patients develop very unpleasant withdrawal symptoms if the drug is stopped abruptly.

Theoretically, antidepressants when used with triptans, such as sumatriptan can cause serotonin syndrome, but it is extremely rare and millions of people take both without any problems.