Triptan Use Not Found to Increase Vascular Comorbidity Among Older Migraine Patients

Triptans are contraindicated in patients with ischemic heart disease, cerebrovascular disease, uncontrolled hypertension, and peripheral artery disease.

Regular evaluation of contraindications against triptans and for vascular risk factors is recommended in patients older than 50 years of age with migraine, according to a study published in Headache. In a cohort of patients older than 50 years of age with migraine, the study authors did not find an increase in the prevalence of vascular diseases among triptan users, which suggests that the risk of vascular events does not increase by triptan use or overuse in this population, according to the study.

Triptans, which act as serotonin 1B/1D receptor antagonists, target migraine attacks that have a vasoconstrictive effect, with their use restricted among patients with vascular disorders.

As such, triptans are contraindicated in patients with ischemic heart disease, cerebrovascular disease, uncontrolled hypertension, and peripheral artery disease. Lead study author Karin Zebenholzer, MD, assistant professor of neurology, Medical University of Vienna, and colleagues sought to determine whether triptan use is a risk factor for vascular diseases in patients over 50 years of age and whether adherence to contraindications is supported by population-based data.

The investigators evaluated an Austrian insurance database from 2011 with prescription data for approximately 3.11 million individuals older than 50 years of age, of whom 13,833 (0.44%) of had at least 1 prescription for triptan. To evaluate variations in the prescriptions of vascular drugs, vascular diagnoses, and hospitalizations, 41,400 nonusers were included as a control group.

Nearly half (49.4%) of triptan users had at least 1 vascular drug prescribed and 6.3% had at least 1 inpatient vascular diagnosis. Triptan users were found to have a small, but statistically significant increase in the odds of being dispensed a vascular medication (odds ratio [OR], 1.10; 95% CI, 1.06-1.15).

Triptan users had statistically significant increases of 35%, 19%, and 28% in cardiac therapies, beta blockers, and heparins used, respectively, versus nonusers. Further, this patient group had statistically significant lower odds of being administered calcium channel blocks (18% decrease), renin/angiotensin inhibitors (25% decrease), and vitamin K antagonists (19% decrease).

Additionally, the calcium channel blocker flunarizine approved for migraine and vestibular migraine was administered to 3% of triptan users versus 0.1% of nonusers (OR, 20.7).

"These data and our previous study showed that triptans are generally under-prescribed in Austria, perhaps also because of the fear of vascular complications," the study authors wrote. "However, this study supports the safety of triptans, even in persons over 50 years of age and with vascular comorbidities. Nonetheless, neurologists and general practitioners should have an eye on patients over 50 who have migraine."

The study authors found that in the second half of 2011, 42.3% of 11,036 individuals prescribed triptan had any vascular medication and/or vascular diagnosis in the first half of 2011. Among 11,157 individuals with a triptan prescription in the first half of 2011, 43.6% also had a vascular medication or diagnosis in the first half of 2011, of whom 70.6% had at least 1 triptan prescription during the second half of 2011.

The study authors did not find statistically significant differences in the prevalence of any vascular diagnoses among users and nonusers (6.3% vs 6.3%; OR, 1.00; 95% CI, 0.93-1.09). However, the odds of having at least 1 hospital inpatient admission grew by 39% for triptan users versus the control group (OR, 1.39; 95% CI, 1.33-1.45), although the length of hospital stay was similar between the groups.

Age was not found to significantly alter the differences between triptan users and the control group regarding the prevalence of vascular diagnoses (age 55: OR, 0.92 [95% CI, 0.78-1.08]; age 70: OR, 1.00 [95% CI, 0.86-1.16]; interaction, = .605), and hospitalization rate (age 55: OR, 1.39 [95% CI, 1.29-1.51]; age 70: OR, 1.33 [95% CI, 1.20-1.48]; interaction, = .510).

However, age was found to significantly alter the differences between triptan users and the control group in vascular medication (age 55: OR, 1.17 [95% CI, 1.09-1.25]; age 70: OR, 0.97 [95% CI, 0.86-1.09]; interaction, <.0001).

REFERENCE
1. Zebenholzer K, Gall W, Gleiss A, Pavelic AR, Wober C. Triptans and vascular comorbidity in persons over fifty: findings from a nationwide insurance database- a cohort study. Headache. Published online May 20, 2022. doi:10.1111/head.14304