One of the recent threads on headaches has given me the e-courage to ask something that I’ve been thinking about for some time… here it goes:

With my PCS, chronic and fairly intense headaches are a daily battle for me. Current pain mitigation relies primarily on BotoxA injections, nortryptiline (50 mg), and Cymbalta (120 mg), but supplementation with Tylenol 3s is frequent. At various stages of my recovery when pain interventions (botox, antidepressants) have been introduced, the removal of some pain leaves my head feeling very messed up, and remains that way. The more pain that is removed, the more screwed up my head feels.

To draw an analogy, if your brain was represented by 2 eggs (each egg is a lobe) in a bowl (your skull), a “normal” brain would have two yolks individually separated and easily recognizable. In my case, with a significant amount of pain removed, my brain would be best represented by two heavily scrambled eggs.

While the pain reduction is very much welcomed, having a “mind” that feels so messed up is both bothersome and worrisome. Prior to the accident, if I took an analgesic for headache pain my head felt “normal”. I’m concerned the “messed up” feeling is my new reality for the long-term.

I know most of us feel very different post-concussion, but has anyone else experienced this phenomenon linked to pain removal?

I did have one cranial sacral experience with a physical therapist. Initially after the treatment, I experienced more pain than when I went in. After a day, I felt 50 percent improvement. She said that the initial feeling I experienced was a "release" of pain and during that release, I would experience more pain and then relief. If that makes any sense but I'm sorry to hear about your confusion and hope you get some answers.

MicroMan,

I'm confused. AD meds need weeks of use to see a benefit. Are you going on and off the AD meds ? By Tylenol 3's, do you mean narcotics (Tylenol with codeine)? Have you ever tried Tylenol and aspirin combined ? You can safely take both at maximum doses. My doc told me to take both. For me, they work better than Tylenol with codeine and do not have addiction risks. Just take breaks from Tylenol once a week.

Cymbalta is known to cause some messed up feelings, especially at high doses. 120 mgs is the maximum dose and more than the 60 mg dose that shows maximum benefit. You may be struggling with serotonin syndrome.

I would say that the different medications are incorrectly interacting with your brain causing some serious side effects. It sounds like you should try and limit the amount and variety of substances used. Try and narrow down the root cause that puts you in this "scrambled" state. It could be one of the drugs, it could be an interaction between two of them or you might need a complete overhaul of your medication regimen.

I understand that your pain takes priority, but you can't let it cloud your judgement. Pharmaceuticals are extremely potent and can be dangerous especially in combination. This mind state you describe can't be helping your brain to heal. Remember the injured brain is extremely sensitive to foreign substances. Please discuss this with your prescribing physician. Ideally the right painkilling substances will have minimal side effects and not increase your concussion symptoms. You don't want to add chemical insult to your existing brain injury.

Not a doctor here, but personally I would be concerned about taking Duloxetine (Cymbalta) and Nortriptyline together esp. since you're taking a high dose of the Cymbalta.

Then there is the codeine added as well.

Did the same doctor order the Nortriptyline and Cymbalta together or separate doctors?

Check out a drug/drug interactions checker like this one
http://www.drugs.com/drug_interactions.html

As always, thanks so much to all who provided their thoughts. I’ll jot some responses below to see if that helps clarify:

Mark: Very astute. Yes, I am in a transition phase. Whilst I have been on 60 mg of Cymbalta for over a year (helped with mood, but not pain at all), a new Psychiatrist is altering my regimen. After giving Nortryptilne a try out as a replacement for Amitryptiline, the plan is to get off Nortryptiline. As part of this process, I’ve done 2 weeks of 90 mg and now at 2 weeks of 120 mg Cymbalta while still taking 50 mg nortryptiline. I meet with the Psych in 2 weeks and I believe I will be withdrawn from the nortryptiline. I’ll give your suggestion a try on the pain relievers. If it gets me away from the codeine, that’d be a huge positive.

DannyT: Completely agree… this state can’t be helpful for recovery.

Lara: Good pick up on the Cymbalta and Nortryptiline issue. The next move is to remove the Nortryptiline, which I welcome… I’m not a fan of the two TCA class A/Ds I’ve tried, though the sedative effects at bed time were nice. Thanks (and Mark as well) for suggesting Serotonin Syndrome… I think you’re spot on. I’ve been a cantankerous bugger, and my better-half told me yesterday that she’s not a fan of the “new” me. Heck, I’m not a fan of the new me!!

Thanks for the help guys… I’m very glad I posted this. It’ll help my discussion with my upcoming meeting with my psych.

Why are you taking so much Cymbalta ? The literature says there is no benefit beyond 60 mgs per day. The high and overlapping doses you are on are as if you are struggling with life threatening severe depression, not headaches and insomnia.

Why is a psychiatrist treating you rather than a pain specialist or physiatrist or neuro ? Was the psych prior to the concussion ? Have you tried anything besides the Cymbalta ?

Gabapentin and even Lyrica have a better track record as off-label meds for headaches.

Check out this pdf about concussion starting at page 17 http://weillcornellbrainandspine.org...ff-SECURED.pdf

The literature I read years ago mentioned how low dose amitriptyline (10 mgs) before bed was optimum for head aches and insomnia. More was not usually better.

Just some ideas for you to consider.

Hi Mark,

The Cymbalta was prescribed to aid with my mood (depression) and for pain relief; I guess it’s used to relieve pain for people enduring fibromyalgia. The dose I was on for the past year was 60 mg; this aided slightly in mood and did nothing for headache pain. A Neuro I saw then added 25 mg of amitryptiline; this afforded a slight reduction in pain and slightly more when it was increased to 50 mg. However, the side ffects were pretty intense. Because of this I was transitioned to 50 mg of nortryptiline while remaining on the 60 mg Cymbalta.

More recently when I met with 2 Psychs and discusse the side effect issues with both TCA class A/Ds, they thought that Cymbalta would be the best choice for two reasons: i. they thought a higher dose would afford better pain control, ii. the higher dose may alleviate some of the depression that they felt I was still in. Over the past month, I’ve done 2 weeks on 90 and 2 weeks at 120 mg. At 90 there was a significant reduction in pain that didn’t occur at 60 mg. At 120, there may be slightly more reduction, but it’s hard to know for sure. However, both doses display far more efficacy than the 60 mg dose, which in my opinion was ineffective. Two notable side effects are an increase heart rate (up 10 bpm) and an increase in my blood pressure, which is already high.

So, why is a Psych the prescribing doc? It relates to two Psychs and one NeuroPsych believing that my current headaches are from depression, rather than the mTBI. Personally I do not believe this to be the case. It is currently the prescribing Psych who is currently trying to determine which is the causative etiology.

Awesome thought on the Pain Specialist; I’m seeing one in Nov. I wish I had been on this forum much earlier as I believe this specialist will be immensely beneficial. Also, I really, really appreciate the options for headache control. I’ll definitely be bringing these as possible options to my next appointment.

Lastly, that link to the Cornell presentation is fantastic… thanks!!

After 14 years on an SSRI, I would never go on a high dose SSRI again. I believe it permanently changed how my brain works. There is evidence to support that.

I am doing much better on 5-HTP and L-Theanine that I ever did on 60 mgs of paroxetine. The symptoms of serotonin syndrome were evident. The mood changes were evident. The flat affect was miserable.

Cymbalta is an SNRI. Regardless, I hear you on the mood changes. I'm having a difficult time controlling them effectively, particularly with the kids. Also, you're right on that flat feelings... I have that in spades. In fact, I'm losing interest in things I love and feel like there's nothing that excites or makes me happy.

Glad I made this post... thx