Vascular Health and Treating Migraine

As new migraine treatments have become available that do not have cardiovascular contraindications, many questions have arisen regarding whether a new therapy—lasmiditan—is truly safe for those with cardiovascular risk. 

These important considerations for the 12% of people in the US who have migraine were discussed in a plenary session at the Virtual Scottsdale Headache Symposium 2020. 

The category of cardiovascular disease as a whole is ill-defined and may include many other conditions. Using the American Heart Association definitions and regulatory requirements of the Food and Drug Adminstration (FDA) vascular disease is considered as coronary vascular disease, cerebrovascular disease, and other bed vascular disease. 

Animal studies and in vitro studies of human and animal blood vessels have shown that the -ditans, including recently approved lasmiditan, do not cause constriction of coronary or cerebrovascular blood vessels, whereas the older agents, the triptans, do cause blood vessel narrowing. The difference between the triptans and -ditans is thought to be a result of action at different subtypes of serotonin receptors. Lasmiditan does have other side effects that warrant caution, however, including dizziness, sedation, and a small risk of abuse. 

Current research on triptans, however, suggest that the cardiovascular contraindications on the prescribing information may not be evidence-based. It was noted that the contraindication of uncontrolled hypertension is not defined and that in clinical trials, certain triptans did not increase blood pressure. Although ergotamines increase risk of ischemic cardiac events, meta-analysis of approximately 130,000 people treated with triptans showed this has not been seen in people treated with triptans. The risk of cardiovascular events with nonsteroidal anti-inflammatory drugs (NSAIDs) may, in fact, be higher than the risk of cardiovascular events with triptans. Myocardial infarction has no vasoconstrictive causation and risk is not associated with triptans, although in Prinzmetal angina, vasoconstriction is involved and triptans should be avoided. However, triptans should not be taken in migraine with aura because of the theoretical increased stroke risks. Despite this research, physicians should take heed that the FDA labeling of triptans continues to have contraindications against use of triptans in people with cardiovascular risk factors.