Triptans for Migraine Patients With Vascular Risks: New Insights, New Options

Abstract

Triptans remain a first-line therapy for acute migraine. Even 25 years after the commercialization of sumatriptan, clinicians still face challenges related to prescribing triptans for patients with cardiovascular risk factors or events. Our understanding of migraine and the triptans vis-a-vis cardiovascular risk factors and arterial physiology has evolved, but has this more detailed knowledge led to any meaningful change in clinical management? Case 1: Cardiovascular Risk Factors.—A 56-year-old male is sent to you for assessment of migraine without aura. He has a history of diabetes, hypertension, and smoking. He is using naproxen with partial success but still endures disabling attacks. Would you prescribe a triptan to this patient? How could you quantify his risk? Should he keep using naproxen? Case 2: Ischemic Stroke.—A 37-year-old woman presents with a history of migraine with aura since childhood. She reports a right anterior cerebral artery distribution ischemic stroke in the context of a cervical artery dissection 5 years ago. A CT scan of the brain with angiogram confirmed complete recanalization of the carotid artery, and she recovered fully from her symptoms. Non-steroidal anti-inflammatory drugs are not effective for her acute headaches, and she tried her sister's eletriptan with great success. Are you willing to prescribe eletriptan to her? Questions: