Migraine Management: How to Treat Patients With Vascular Disease

The use of triptans is contraindicated in patients with migraine and a history of ischemic stroke or coronary artery disease, although there’s no substantial evidence that they directly increase the risk for vascular events.

The frequency of vascular diseases, including arterial hypertension, coronary heart disease, and stroke have been associated with migraine. The presence of these vascular diseases in patients with migraine can influence treatment options. Treatments that target migraine severity and frequency and also improve vascular comorbidity are considered.

A review published in Headache discusses the potential treatment options for acute migraine attacks and for migraine prevention in patients with vascular disease, and elaborates on the association between treatment with triptans and the risk for vascular disease.1

Triptans are the most commonly prescribed treatments for acute migraine attacks; however, these drugs are contraindicated in patients with uncontrolled arterial hypertension, coronary artery disease (CAD), and after a stroke or transient ischemic attack.1

The Relationship Between Migraine and Arterial Hypertension

Multiple studies have addressed the relationship between migraine and hypertension, with data suggesting a positive association between the 2 entities; hypertension may lead to a higher frequency and severity of migraine attacks. 2,3

Several antihypertensive medications may be useful in migraine prophylaxis, particularly, beta-blockers, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers.1,2

While acetylsalicylic acid, acetaminophen, and NSAIDs may be used to treat migraine in patients with arterial hypertension, triptans should not be used in those with uncontrolled hypertension, though the definition of “uncontrolled” in literature has been vague.1

A meta-analysis to determine the efficacy of preventive pharmacologic treatments for migraine in adults reported that various beta-blockers, including propranolol, metoporlol, atenolol, and nadolol, as well as angiotensin-converting enzyme (ACE) inhibitors captopril and lisinopril, and angiotensin receptor blocker (ARB) candesartan, were superior to placebo in reducing monthly migraine frequency by 50% or more.4

In a review of randomized trials, Tullo and colleagues evaluated the efficacy of triptans in the management of acute migraine in patients with a history of arterial hypertension. During treatment with triptans, there was no increase in blood pressure or heart rate in patients with hypertension and the tolerability was similar in those with and without hypertension. However, patients with hypertension tended to be less responsive to triptans than patients with normotension.5

In light of available data and in accordance with FDA approval, triptans should not be used for acute migraine attacks in patients with uncontrolled hypertension, specifically during a hypertensive crisis. With regard to migraine prophylaxis, beta-blockers and angiotensin-inhibiting drugs may be considered in the prevention of migraine attacks and control blood pressure.1,4

Migraine With and Without Aura and Cardiovascular Disease (CVD) Risk

The risk for CVD and myocardial infarction (MI) is increased in patients with migraine, with or without aura and independent of drug therapy.1

A meta-analysis of 16 observational cohort studies with more than 1.1 million individuals reported that migraine was associated with a higher risk for major adverse cardiovascular and cerebrovascular events, mainly secondary to a higher risk for long-term stroke and MI. Compared with patients without aura, those with aura had worse cardiovascular and cerebrovascular outcomes, including stroke and MI.6

Triptans are contraindicated in patients with ischemic heart disease because of concerns about vasospasm of coronary vessels that could lead to myocardial ischemia. However, it is now believed these drugs activate serotonin (5-HT) 1D receptors.1

According to the FDA approval document for sumatriptan, the contraindications for use include ischemic cardiac diseases, ischemic CAD (angina pectoris, history of myocardial infarction, or documented silent ischemia), or coronary artery vasospasm, including Prinzemetal’s angina. However, data published after triptans approval showed that the risk for acute coronary syndrome in the treatment of acute migraine was extremely low.1

This article originally appeared on Neurology Advisor