Ignore fearmongering: triptans still do not increase the risk of strokes and heart attacks

A group of highly respected researchers at the Albert Einstein College of Medicine just published their second article in the journal Headache on the cardiovascular disease (CVD) risks in migraine sufferers. Not surprisingly, they have found that there is an increase in the CVD risk factors with increasing age – more people develop diabetes, hypertension, heart attacks, strokes, get stenting and other heart procedures as they get older.

This study concludes that, “Among people with episodic migraine in the US population, the number of women and men with relative contraindications to triptans… includes over 900,000 women and men. This includes more than half a million individuals with episodic migraine who have not had a prior cardiovascular events or procedures.” They also extensively refer to the FDA-approved label for triptans, which says that “It is strongly recommended that sumatriptan not be given to patients in whom unrecognized coronary artery disease is predicted by the presence of risk factors…”. This is because triptans can slightly constrict blood vessels, especially diseased ones (but vasoconstriction is not how triptans relieve migraines).

This is a strange conclusion considering that in the first article devoted to this large and extensive study they admit that “Serious cardiac events following triptan administration are very rare and in claims analysis, triptan use is indeed not associated with increased risk of CVD”. And the triptan label includes this statement (mentioned by the authors): “Considering the extent of use of sumatriptan in patients with migraine, the incidence of these events (drug-associated cardiac events and fatalities) is extremely low.”

The first study reported that there is a decline in the use of triptans in patients with CVD risk factors. The authors note that “It is our impression that this finding reflects a “fear-factor”; doctors may fear the onset of CV events in individuals with migraine and patients may fear the triptan label. Therefore, migraineurs that could theoretically benefit from triptans do not receive them. Nonetheless, it must be emphasized once more that triptans are not associated with the migraine/CVD relationship in populational studies; that no evidence exists to suggest increased risk of CVD in individuals with specific risk factors; and that triptans are not contraindicated in individuals without CVD but with risk factors for it.”

In the second study they inexplicably change their tune and say that “Nonvasoconstrictive acute treatments for migraine may be particularly valuable in persons of both sexes, especially men over the age of 40 and women over the age of 60. In addition, as the population ages, migraine treatments that do not constrict blood vessels may play an increasingly important role.”

What “nonvasoconstrictive acute treatments”? NSAIDs, such as ibuprofen and naproxen? Regular intake of NSAIDs, unlike that of triptans, is proven to increase the risk of CVD. Narcotics? They do not work well for most migraine sufferers and fuel the addiction epidemic. Butalbital/caffeine combination? It does not help most migraine sufferers (and was never approved for migraines) and, unlike triptans, cause medication overuse headaches.

Fortunately, patients with severe coronary artery disease and other strong contraindications for the use of triptans will soon have a safe option in a new category of migraine drugs, CGRP antagonists. They do not have any effect on blood vessels and will not have a warning label about their use in patients with CVD risk factors. However, these are very new drugs and we do not have long-term safety data that we have for triptans. Triptans have been in use for over 25 years and are sold without a prescription in most European countries.

The first group of these CGRP drugs, which will be released next year, will be given by injection for the prevention of migraines. In about 2-3 years we also hope to have CGRP drugs in a tablet form for the treatment of acute attacks. These will be expensive drugs, but their development has cost billions of dollars, so I have no quarrel with that (but insurance companies will). However, even if price was not an issue, a triptan would still be my first choice for most patients.

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