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Triptan Use Shows No Significant Vascular Comorbidity Increase for Older Patients With Migraine

In triptan users, prescriptions of cardiac therapies and beta blockers were significantly more common compared with other prescriptions of calcium channel blockers and renin/angiotensin inhibitors, which were significantly less common.

Using a cohort of patients older than 50 years with migraine, findings showed no increase in the prevalence of vascular diseases among triptan users, implying that the risk of vascular events does not escalate by triptan use, or even by triptan overuse, in this age group.1 Despite these data, investigators concluded that regular evaluation for contraindications against triptans and for vascular risk factors is recommended in this age group.

Triptans, working as serotonin 1B/1D receptor antagonists, are specific treatments for aborting migraine attacks that have a vasoconstrictive effect, restricting their use among those with vascular disorders. According to their labeling, triptans are contraindicated in persons with ischemic heart disease, cerebrovascular disease, uncontrolled hypertension, and peripheral artery disease. Lead author of this effort, Karin Zebenholzer, MD, assistant professor of neurology, Medical University of Vienna, and colleagues aimed to evaluate if triptan use constitutes a risk factor for vascular diseases in patients over 50 years and if adherence to contraindications is supported by population-based data.

Using an Austrian insurance database from 2011, prescription data was pulled for 3,116,000 persons older than 50 years, 13,833 (0.44%) of whom had at least 1 triptan prescription. To understand differences in the prescriptions of vascular drugs, vascular diagnoses, and hospitalizations, 41,400 nonusers were included as controls. Of users, slightly less than half (49.4%) had at least 1 vascular drug prescribed and 6.3% had at least 1 inpatient vascular diagnosis. Triptan users showed a small, but statistically significant increase in the odds of being dispensed any vascular medication (odds ratio [OR], 1.10; 95% CI, 1.06-1.15).

Compared with nonusers, triptan users had statistically significant increases of 35%, 19%, and 28% in cardiac therapies, beta blockers, and heparins utilized, respectively. Additionally, these patients had statistically significant decreased odds of being dispensed calcium channel blocks (18% decrease), renin/angiotensin inhibitors (25% decrease), and vitamin K antagonists (19% decrease). Notably, flunarizine, a calcium channel blocker approved for migraine and vestibular migraine, was dispensed to 3% of triptan users compared with 0.1% of nonusers (OR, 20.7).

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"These data and our previous study showed that triptans are generally under-prescribed in Austria, perhaps also because of the fear of vascular complications," Zebenholzer et al wrote. "However, this study supports the safety of triptans, even in persons over 50 years of age and with vascular comorbidities. Nonetheless, neurologists and general practitioners should have an eye on patients over 50 who have migraine."

Despite the prescription of vascular medications and the presence of vascular diagnoses, patients continued to receive triptan prescriptions. In the second half of 2011, of 11,036 triptan users with a triptan prescription, 42.3% had any vascular medication and/or vascular diagnosis in the first half of 2011. Of 11,157 triptan users with a triptan prescription in the first half of the year, 43.6% also had a vascular medication or diagnosis during the first half of 2011. Of those, 70.6% had at least 1 triptan prescription in the second half of 2011.

Between users and nonusers, investigators did not find statistically significant differences in the prevalence of any vascular diagnoses (6.3% vs 6.3%; OR, 1.00; 95% CI, 0.93-1.09). Despite this, the odds of having at least 1 hospital admission as an inpatient was increased by 39% for triptan users compared with controls (OR, 1.39; 95% CI, 1.33-1.45), although the length of hospital stay did not differ between groups.

Age did not significantly modify the differences between triptan users and controls concerning the prevalence of vascular diagnoses (age 55: OR, 0.92 [95% CI, 0.78-1.08]; age 70: OR, 1.00 [95% CI, 0.86-1.16]; interaction, P = .605), and hospitalization rate (age 55: OR, 1.39 [95% CI, 1.29-1.51]; age 70: OR, 1.33 [95% CI, 1.20-1.48]; interaction, P = .510). In contrast, age significantly modified the differences between triptan users and controls regarding vascular medication (age 55: OR, 1.17 [95% CI, 1.09-1.25]; age 70: OR, 0.97 [95% CI, 0.86-1.09]; interaction, P <.0001).

REFERENCE
1. Zebenholzer K, Gall W, Gleiss A, Pavelic AR, Wober C. Triptans and vascular comorbidity in persons over fifty: findings from a nationwide insurance database- a cohort study. Headache. Published online May 20, 2022. doi:10.1111/head.14304