A study published in the current issue of JAMA Neurology examined the risk of stroke and myocardial infarction (heart attack) after starting a triptan. Triptans have been in use for over 30 years and include drugs such as sumatriptan (Imitrex), rizatriptan (Maxalt), and five others. In many countries, they are sold without a prescription. Danish researchers identified 429,612 individuals who redeemed their first prescription for a triptan.
Unlike all previous studies, they found a slight increase in the risk of stroke or heart attack. Surprisingly, in the abstract of this report, the authors present higher unadjusted numbers than in the discussion section. Of those 429,612 patients, 13 had a heart attack or a stroke within a week or two after they filled the prescription. This means that the risk is 1 in 30,000. Notably, patients who suffered from a stroke or heart attack were older than 60 and had risk factors for cardiovascular disease, such as hypertension, diabetes or previous heart attacks and strokes.
The authors concluded that their study supports the current US FDA recommendation that triptans should not be prescribed to patients with a history of coronary artery disease, transient ischemic attacks, or stroke. They also stated that their “findings do not raise concern” about triptan use in patients with low cardiovascular risk.
In a previous post, I mentioned a report that found NSAIDs such as ibuprofen, and naproxen to be more likely to cause major cardiovascular events than triptans in a ratio of 3.8 to 1. Fortunately, in high-risk patients, we can skip triptans and NSAIDs and use a new class of drugs to treat an acute migraine attack. CGRP antagonists do not increase the risk of cardiovascular events. These drugs are rimegepant (Nurtec), ubrogepant (Ubrelvy), and zavegepant (Zavzpret).
