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October 10 Highlight and Commentary

Triptan and ergotamine overuse in patients with headache at risk for vasoconstrictive complications

In a case-control study, Wammes-van der Heijden et al. investigated whether the intensity of triptan and ergotamine use is associated with the risk of ischemic complications. Triptan overuse did not increase this risk. Overuse of ergotamine proved to be a risk factor, especially in patients with concomitant use of cardiovascular drugs (8.5-fold increase).

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Triptan and ergotamine overuse in patients with headache at risk for vasoconstrictive complications

Commentary by Mark Obermann, MD, and Zaza Katsarava, MD, PhD, MSc

Medication overuse headache (MOH) has developed into the third most common type of headache after tension-type headache (TTH) and migraine. The prevalence of MOH is approximately 1% of the world’s population and may be increasing: recent studies show that it occurs at all ages, often starting in childhood. Virtually any anti-headache drug is capable of inducing MOH¹: triptans, ergots, opioids, and other analgesics, as well as commonly used combinations

The study by Wammes-van der Heijden et al. reviews the possible risk of vasoconstrictive complications in patients with MOH using triptans and ergots. They found that triptan overuse was not associated with an increased risk for vasoconstrictive complications, even in patients with concomitant cardiovascular risk factors, while patients who overused ergotamine had a two times higher risk for ischemic complications. The risk of ergotamine was increased almost fourfold in patients with additional cardiovascular risk factors.

This study has methodologic limitations: ICD-9 codes may not accurately reflect the patients’ diagnosis; exact time period of triptan and ergotamine intake could not be defined; possible confounders were not well controlled, e.g., type of associated risk factors, possible interactions of co-medication. However, the study contributes important information on the safety of triptan use in clinical neurology practice and underlines the apparent dangers associated with ergotamine in headache treatment especially in older patients at risk for cardiovascular complications. The prevalence for MOH in the general population is on the rise in all age groups.² In the past triptans may have been prescribed less frequently because of concerns about their cardiovascular side effects.³ If the concerns about cardiovascular side effects are unwarranted, wider use of triptans might prevent the development of MOH.

This study was not able to distinguish among cerebral, coronary, and peripheral vasoconstrictive events and could not quantify the safety in low vs high cardiovascular risk patients. Therefore, triptan prescription still has to be carefully evaluated for the individual patient. General recommendations cannot be given until further, prospective research is conducted. This study suggests that a prospective trial of triptans is justified in patients who would previously have been excluded from treatment.

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References

1. Limmroth V, Katsarava Z. Medication overuse headache. Curr Opin Neurol 2004;17:301–306.[Medline]
2. Wang SJ, Fuh JL, Lu SR, Juang KD. Chronic daily headache in adolescents: prevalence, impact, and medication overuse. Neurology 2006;66:193–197.[Abstract/Free Full Text]
3. Hall GC, Brown MM, Mo J, MacRae KD. Triptans in migraine: the risks of stroke, cardiovascular disease, and death in practice. Neurology 2004;62:563–568.[Abstract/Free Full Text]

This Article Full Text (PDF) Correspondence: Submit a response Alert me when this article is cited Alert me when Correspondence are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content Related Collections Related Article