Serotonin (5-hydroxytryptamine, 5-HT) acts via 13 different receptors in humans. Of these receptor subtypes, all but 5-HT1eR have confirmed roles in native tissue and are validated
drug targets. Despite 5-HT1eR's therapeutic potential and plausible druggability, the mechanisms of its activation remain elusive. To illuminate 5-HT1eR's pharmacology in relation to the highly homologous 5-HT1FR, we screened a library of aminergic receptor
ligands at both receptors and observe 5-HT1e/1FR agonism by multicyclic drugs described as pan-antagonists at
5-HT receptors. Potent agonism by tetracyclic
antidepressants mianserin,
setiptiline, and
mirtazapine suggests a mechanism for their clinically observed anti-
migraine properties. Using cryoEM and mutagenesis studies, we uncover and characterize unique agonist-like binding poses of
mianserin and
setiptiline at 5-HT1eR distinct from similar
drug scaffolds in inactive-state 5-HTR structures. Together with computational studies, our data suggest that these binding poses alongside receptor-specific allosteric coupling in 5-HT1eR and 5-HT1FR contribute to the agonist activity of these
antidepressants.