SAN DIEGO – Triptans are routinely prescribed to migraine patients who have a history of cardiovascular disease, according to evidence from a large medical claims database study.
Serotonin (5-HT) receptor agonists are among the most commonly prescribed medications for migraine patients, but are contraindicated in patients with a history, signs, or symptoms of ischemic cardiac, cerebrovascular, or peripheral vascular syndromes; any other underlying cardiovascular disease; or uncontrolled hypertension, according to package inserts.
Daisy S. Ng-Mak, Ph.D., of Merck Sharp & Dohme, and her colleagues randomly selected 10 representative health plans from MedAssurant Inc.'s MORE
Among those patients, 22% had received a prescription for a triptan during 2009, the authors reported at the meeting.
The MedAssurant MORE
Dr. Ng-Mak and her coauthors identified migraine patients through chart diagnoses, prescription claims, or treatment of at least two headaches at least a week apart. They similarly found cardiovascular contraindications by either diagnosis or prescription claim data.
Among patients aged 18-49 years with such a cardiovascular contraindication, 24% received a triptan prescription.
“Especially … concerning,” the authors noted, was the fact that 21% of older migraine patients with cardiac contraindications at the time of the study had received a triptan prescription.
These 50- to 64-year-olds “may be exposed to other risks” that heighten cardiac concerns, Dr. Ng-Mak said.
In an interview following the meeting, Dr. Ng-Mak said she found the findings “quite eye catching.”
“We really don't know why we saw this high percentage – a shocking percentage – of patients with cardiac contraindications [who were] receiving triptans,” she said.
Dr. Juline Bryson, a neurologist and headache specialist at St. Luke's–Roosevelt Hospital Center, New York, said “overfamiliarity” may be to blame.
In the 20 years since the introduction of sumatriptan, the drug class has greatly expanded and has been widely accepted as efficacious therapy for migraine, she said.
“We may be getting so comfortable with prescribing triptans these days that we almost think of them like Aleve or Advil” said Dr. Bryson, who was not affiliated with the database study.
In brief, 10-minute visits, primary care physicians may not be taking the time to carefully consider the patient's history when they decide to quickly prescribe something for migraine pain.
Another neurologist unaffiliated with the study, Dr. Matthew S. Robbins, said that patients often arrive at the Montefiore Headache Center in New York with a history of taking triptans that long predates their cardiovascular history.
When the patient was “young and healthy” many years before, he or she received a triptan prescription for migraines, was satisfied, and kept requesting it, he speculated. At some point along the way, a cardiovascular condition developed, but physicians kept refilling the triptan prescription without realizing that the drug was now contraindicated.
“I have had to refuse to refill the prescriptions over the severe protest of the patient, because [the drug had] worked so well,” said Dr. Robbins, a neurologist at Montefiore Medical Center in New York.
A separate study – the U.S. population–based AMPP (American Migraine Prevalence and Prevention) study – found that 10% of 5,591 individuals with episodic migraine reported that they had experienced a major cardiovascular event, such as stroke or MI, or a cardiovascular procedure.
The analysis examined five areas of unmet need among persons with episodic migraine, including cardiovascular event history, reported Dawn C. Buse, Ph.D., of the department of neurology at the Albert Einstein College of Medicine and director of behavioral medicine at the Montefiore Headache Center, both in New York.
More than 40% of episodic migraine patients met criteria for at least one type of unmet need related to acute headache medications, including dissatisfaction with treatment (15.2%), moderate to severe headache-related disability (19.2%), excessive use of opioids or barbiturates (13%), and two or more visits a year to an emergency department or urgent care center for headache (2.3%).
According to Dr. Buse, “these data demonstrate that despite the existing armamentarium of acute headache therapies, many individuals with headache are not receiving satisfactory results. This is likely due to a range of factors, which may include limited access to care, cost barriers, and limitations of existing acute treatments for migraine.”
In this portion of the study, patients with cardiovascular disease were not asked whether they were taking triptans, but in a previous report from AMPP, widespread triptan use was seen in migraineurs (Headache 2010;50:256-63).
That study found triptan use in 8.5% of patients with a history of MI, in 7% of those with a history of stroke, in 9% of patients who had undergone heart surgery, in 16% of patients with transient ischemic attacks, and in 18% of patients with a history of claudication.