Triptan Use Remains Prevalent Among Patients With Migraine and Cardiac Contraindications
Although triptans are the gold standard for the treatment of migraine, more investigation is needed regarding their use among patients with cardiovascular risk factors, according to researchers.
SAN DIEGO—Nearly one-quarter of patients with migraine who also have a cardiac contraindication had a triptan prescription filled in 2009, despite known safety concerns about use of triptans in this population, according to research presented at the 136th Annual Meeting of the American Neurological Association.
“This study demonstrates potential concerns regarding pharmacotherapy for migraine,” stated lead author Daisy S. Ng-Mak, PhD, Director of Global Health Outcomes at Merck Sharp & Dohme Corporation in West Point, Pennsylvania, and colleagues. “While we recognize that triptans remain the gold standard for acute migraine treatment, their high utilization (22%), especially among the 50- to 64-year-old population with cardiac contraindications and who may be exposed to other risks, is concerning and deserves further study.”
Due to the vasoconstrictive mechanism of triptans, labeling on the drugs cautions that they should not be used in patients who have significant underlying heart disease, a previous heart attack, a history of stroke or transient ischemic attack, peripheral vascular disease, or uncontrolled high blood pressure.
“We encourage physicians to review the labeling for triptans regarding potential cardiac contraindications, and to appropriately monitor patients at risk, when triptans are prescribed,” lead investigator Neil I. Goldfarb, who is the Executive Director of the Greater Philadelphia Business Coalition on Health, told Neurology Reviews. “Patients also should be made aware of the cardiac risks, as well as the potential benefits, of triptans. Neurologists who are prescribing triptans to patients with cardiovascular risks also should communicate this information directly to the patients’ primary care physicians and/or cardiologists, to improve care coordination.”
Triptans and Cardiovascular Risk
A total of 121,286 patients with migraine were initially identified from a health plan registry by the investigators. Participants were included if they were diagnosed with migraine after visiting a physician, if they had two or more episodes of headache seven or more days apart, or if they had at least one prescription for a migraine drug or migraine analgesic. Cardiac contraindications for triptans were defined as at least one prescription or medical claim indicating a cardiac contraindication.
Among the patients with migraine included in the analysis, 38% had one or more prescriptions for a triptan and 8% had a cardiac contraindication. Twenty-two percent of patients with a cardiac contraindication had a triptan prescription filled during the study period.
When grouped into specific age ranges, the researchers found that 24% of those ages 18 to 49 with a cardiac contraindication had a triptan prescription, and 21% of those ages 50 to 64 with a cardiac contraindication had a prescription for a triptan.
There are a number of potential explanations for the findings, which extend beyond any lack of awareness on the part of clinicians and/or patients, noted Mr. Goldfarb. “It may be that the care was appropriate given the patient’s clinical history and risk-benefit ratio,” he said. “Our study was focused on testing a set of standardized measures of migraine care and establishing performance benchmarks.”
Alternative Treatment Options?
“Triptans currently are the best abortive therapy option for chronic migraine,” study co-investigator Joseph Couto, PharmD, MBA, Assistant Professor at the Thomas Jefferson University School of Population Health in Philadelphia, told Neurology Reviews. “We did find in the study that preventive migraine medications were not being widely used, and that many patients who were prescribed triptans did not also appear to be receiving preventive medications. Therefore, it may be possible to reduce the frequency of migraine episodes, and reliance on triptans, through use of preventive medications, especially for the patients with a cardiovascular contraindication for triptans.”
“We would encourage health plans and physicians to use these findings as a springboard for investigating the appropriateness of migraine pharmacotherapy and improving quality where needed,” Mr. Goldfarb commented.