If you have heart disease, your options for migraine treatment used to be limited. Triptan medications should be avoided. This is because triptans can decrease the diameter of blood vessels which, if already narrowed by heart disease, can potentially restrict blood flow further and result in heart attack. A recent study of over 120,000 people with migraine from 10 health plans revealed that 22% of people with a heart condition prohibiting the use of triptans were nevertheless given a triptan prescription.
Are these migraine-specific drugs unsafe for migraine sufferers without heart disease? Triptans are not known to cause heart disease, and can be safely taken as long as you do not have heart disease. Safety of these medications in migraineurs who have several risk factors for heart disease is not certain, but often alternatives are recommended.
NSAID Risk in Cardiac Patients
Often, nonsteroidal anti-inflammatory medications are offered for migraine pain instead of or in addition to triptan medications. However, you may not know that nonsteroidal anti-inflammatory drugs (NSAIDs) can be even more dangerous. Non-steroidal anti-inflammatory medications can be a cause of risk, even amongst those without heart disease or its risk factors, but is especially risky in cardiovascular conditions. Conditions at particular risk are stroke, unstable angina, recent bypass surgery, or myocardial infarction. NSAIDs tend to elevate blood pressure, and this accounts for some of the cardiovascular risk. In those who already have atherosclerosis, the COX-2 NSAIDs also affect the balance of chemical factors affecting clot formation, tilting things toward clotting.
Using NSIADs increases the risk of recurring myocardial infarctions. Even short term use–as little as seven days–can increase the risk of another myocardial infarction of death by about 50%. (Drugs used most commonly in this study were ibuprofen, naproxen, rofecoxib, and celecoxib.)
For those with known cardiovascular disease or risk factors for ischemic heart disease, aspirin, tramadol, or acetaminophen (paracetamol) have previously been the safest choices for the treatment of pain. Naproxen, although not risk-free, was the safest choice in those who have not responded to those medications. There are now newer options (discussed below.) Narcotic analgesics may be used as rescue medication. These are not, however, the best options for migraine attacks.
NSAIDs should be avoided in those who have heart disease or heart failure. But what about migraine patients who do not have heart disease? Current recommendations are to weigh the benefits of these medications against their risks. If over-the-counter nonsteroidal anti-inflammatory medication is required for more than ten days, you should see a doctor. Also, be aware that ibuprofen can interfere with the ability of aspirin to provide protection against clotting, and should be taken either 30 minutes before or twelve hours after taking low-dose aspirin.
New Options for Migraine Patients with Cardiac Disease
Newer medications for migraine are available that have proven safe in cardiac patients. These include lasmiditan (Reyvow), rimegepant (Nurtec), and ubrogepant (Ubrelvy). All three of these can be used for the acute management of migraine, and have been found to be safe for cardiac patients.
References:
1. American Neurological Association (ANA) 136th Annual Meeting: Poster T1614. Presented September 27, 2011.
2. Antman, EM, Bennett, JS, Daugherty, A, Furberg, C, Roberts, H, Taubert, KA. Use of nonsteroidal antiinflammatory drugs: an update for clinicians: a scientific statement from the American Heart Association. Circulation. 2007; 115:1634-1642.
3. Hammad, TA, Graham, DJ, Staffa, JA, Komegay, CJ, Dal Pan, GJ. Onset of acute myocardial infarction after use of non-steroidal anti-inflammatory drugs. pharmacoepidemiol Drug Sof. 2008; 17:315-321.
4. Fosbol, EL, Gistason, GH, Jacobsen, S, Folke, F, Hansen, ML, Schramm, TK, Sorensen, R, Rasmussen, JN, Andersen, SS, Abildstrom, SZ, Traerup, J, Poulsen, HE, Rasmussen, S, Kober, L, Torp-Pesersen, C. Risk of myocardial infraction and death associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDS) among healthy individuals: a nationwide cohort study. Clin Pharmacol Ther. 2009; 85:190-197.
5. Gislason, GH, Rasmussen, JN, Abildstorm, SZ, Schramm, TK, Hansen, ML, Fosbol, EL, Sorensen, R, Folke, F, Burch, P, Gadsboll, N, Rasmussen, S, Poulsen, HE, Kober, L, Madsen, M, Torp-Pedersen, C. Increased mortality and cardiovascular morbidity associated with use of nonsteroidal anti-inflammatory drugs in chronic heart failure. Arch Intern Med. 2009; 169:141-149.
6. Young, WB, Mannix, L, Adelman, JU, and Schechter, AL. Cardiac Risk Factors and the Use of Triptans: A Survey Study. Headache: The Journal of Head and Face Pain. 2000; 40:587-591.
7. Berman, G, Croop, R, Kudrow, D, Halverson, P, Lovegren, M, Thiry, AC, Conway, CM, Coric, V, Lipton, RB. Safety of Rimegepant, an Oral CGRP Receptor Antagonist, Plus CGRP Monoclonal Antibodies for Migraine. Headache: The Journal of Head and Face Pain. 2020. 60 (8):1734-1742.
8. Shapiro, RE, Hochstetler, HM, Dennehy, EB, Khanna, R, Gautier Doty, E, Berg, PH, Starling, AJ. Lasmiditan for Acute Treatment of Migraine in Patients with Cardiovascular Risk Factors: Post-hoc Analysis of Pooled Results from 2 Randomized, Double-Blind, Placebo-Controlled, Phase 3 Trials. j. Headache Pain. 2019. 29; 20(1):90.
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