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Triptans, DHE not associated with ischemic vascular events for migraine treatment

Triptans and dihydroergotamine were not found to cause ischemic vascular events when used in the treatment of patients with basilar and hemiplegic migraines, according to findings published in Headache.

Paul G. Mathew, MD, FAHS, neurologist and director of continuing medical education at Brigham and Women’s Hospital, and colleagues wrote that while the medications are common first-line treatments for migraines, both have a black box warning for these specific types of migraines because of the risk of stroke or myocardial infarction.

Brad Klein, MD, medical director of the Headache Center at Abington Hospital-Jefferson Health and senior author of the study, commented in a press release about the study that basilar and hemiplegic migraines are believed to cause pain by constricting blood vessels, in contrast to other types that cause a swelling of blood vessels. As triptans and dihydroergotamine (DHE) are believed to relieve pain by constricting blood vessels, patients with basilar and hemiplegic migraines were not initially included in studies for fear of increasing stroke risk.

“As a result, no one ever actually showed that these drugs were dangerous — they were just assumed to be dangerous based on their mechanism of action,” he said in the release. “And recent research suggests that the auras are not due to blood vessel constriction.”

Researchers conducted independent retrospective chart reviews of patients with basilar and hemiplegic migraines who received treatment with triptans or DHE at the following four institutions: Brigham and Women’s John R. Graham Headache Center; Stony Brook University Hospital; Neurology and Neuroscience Associates; and Abington Headache Center and Abington Memorial Hospital. Investigators identified 35 patients who received DHE and 45 patients who received triptans. Among patients who received DHE, 27 had basilar migraines and eight had hemiplegic migraines. Among patients who received triptans, 40 had basilar migraines and five had hemiplegic migraines.

Results showed no adverse events of myocardial infarction or stroke during the follow-up period. The researchers reported five patients in the triptan group experienced gastrointestinal upset, nightmares, rash, flushing and neck dystonia and five patients in the DHE group experienced transient asymptomatic anterior T wave inversion, dystonic reaction, agitation and chest tightness. In addition, researchers calculated statistical event rates of 4.5% for basilar migraine and 23% for hemiplegic migraine, which they wrote, “suggest that further justification is warranted regarding the black box warning for the use of both [basilar migraine] BM and [hemiplegic migraine] HM.”

“Because auras are associated with basilar and hemiplegic migraine, many physicians refuse to give these drugs to any patients experiencing an aura out of a false sense of precaution,” Klein said in the release.

He added, “There are not enough medicines out there to appropriately manage migraine headaches. At a time in history when an unprecedented number of people are getting hooked on narcotic opiates by way of prescribed medications — as is the case with migraine sufferers as well — we owe it to ourselves as physicians to try medications that could work without the risk of addiction.” – by Chelsea Frajerman Pardes

Reference:

http://hospitals.jefferson.edu/news/2016/05/migraine-drugs-underused/

Disclosures: The researchers report no relevant financial disclosures.