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Migraine with aura and risk of cardiovascular and all cause mortality in men and women: prospective cohort study

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3966 (Published 24 August 2010) Cite this as: BMJ 2010;341:c3966

Rapid Response:

Triptan utilization in patients with cardiovascular risk

Two large cohort studies have recently confirmed that migraine with
aura can be considered an important risk factor for cardiac and
cerebrovascular death: Kurth and coll. [1] found a 2-fold increased risk of
haemorrhagic stroke in women who had migraine with aura, whereas
Gudmundsson and coll. [2] found that people suffering of migraine with aura
had a significantly higher risk of all cause mortality and of mortality
for coronary heart disease and stroke.

From the pathophysiological point of view, triptans, which represent the
mainstay of acute migraine treatment, activate the 5-HT1B and 5-HT1D
receptors within the trigeminovascular system, impairing both cerebral
vessels and, to a much lesser extent, coronary arteries and resulting in a
important vasoconstriction. [3] So the risk of vascular events in patients
with migraine could further increase with the triptan use. As a result,
triptans are contraindicated or should be used with caution in certain
patient populations with cardiovascular disease.

Based on a sample of the Italian general population (16,811 new users of
triptan in 2007 out of 4,254,449 inhabitants of the Emilia-Romagna
Region), we analysed the patterns of triptan utilization in a large
community setting. We especially focused on subjects who received triptans
despite the presence of co-prescriptions of cardiovascular drugs, proxy of
a basal vasoconstrictive risk. Twelve percent of new triptan users (2009
patients) received concomitant therapy with cardiovascular drugs, 100
(0.6%) of them received co-prescriptions suggesting a high level risk
according to triptan Summary of Product Characteristic (ATC codes: C01A,
C01B, C01C and C01D), primarily nitrates (glyceryl trinitrate or
isosorbide mononitrate). Moreover, we found that cardiovascular co-
prescription markedly increased with increasing age, reaching the 36.6%
(431/1179) in the elderly (>65), an age group for which triptan are per
se not recommended.

Despite the known increased risk of vasoconstrictive complications, our
data showed a possible basal cardiovascular risk in a not negligible
percentage of triptan recipients suggesting the need to make aware
prescribers in the pharmacological approach to migraine, in particular in
the elderly, in order to improve patient safety.
Applying this easy approach to data from other Countries, a detailed map
of the magnitude of this problem could be obtained and appropriate
regional interventions could be performed.

1. Kurth T, Kase CS, Schurks M, Tzourio C, Buring JE. Migraine and
risk of haemorrhagic stroke in women: prospective cohort study. BMJ
2010;341:c3659.

2. Gudmundsson LS, Scher AI, Aspelund T, Eliasson JH, Johannsson M,
Thorgeirsson G et al. Migraine with aura and risk of cardiovascular and
all cause mortality in men and women: prospective cohort study. BMJ
2010;341:c3966.

3. Jamieson DG. The safety of triptans in the treatment of patients
with migraine. Am J Med 2002;112:135-40.

Competing interests: No competing interests

17 October 2010
Chiara Biagi
sholarship
Giuseppe Roberto, Elisabetta Poluzzi, Domenico Motola, and Nicola Montanaro
Department of Pharmacology, University of Bologna