Cardiovascular Issues Increase Challenges of Migraine Treatment
Migraine meds confusionThe American Migraine Prevalence and Prevention (AMPP) Study survey, conducted in 2009, continues to provide researchers with data that allows insightful analysis of many issues. One such issue is the impact of cardiovascular (CV) events, conditions, and procedures on the acute treatment of episodic Migraine, an issue that has long caused confusion about the safety of acute migraine medications.
"Though Migraine, particularly Migraine with aura, is a cardiovascular (CV) risk factor, the scope and distribution of cardiovascular disease in representative samples of people with Migraine are not known. This is important because many widely used acute Migraine treatments, including triptans, ergot alkaloids, and nonsteroidal anti-inflammatory drugs, carry precautions, warnings, or contraindications for use in persons with CV disease."1
"To assess the scope and distribution of cardiovascular events, conditions, and procedures in persons with episodic Migraine in a representative sample of the US population, using data from the American Migraine Prevalence and Prevention (AMPP) Study."1
- Eligible subjects:
- completed the 2009 AMPP survey
- met ICHD-3beta criteria for Migraine
- had a Migraine frequency of less than 15 days per month (episodic Migraine)
- A survey on cardiovascular events (i.e., myocardial infarction), conditions (i.e., angina), and procedures (i.e., carotid endarterectomy) was adopted from the Women’s Health Study and the Physician’s Health Studies for use in the AMPP Study.
- Cardiovascular events and conditions were defined by participant reports of having both experienced and received a physician diagnosis for a particular event or condition.
- The distribution of CV events, conditions, and procedures was summarized for the entire Migraine sample and in groups defined by gender and age (22–39, 40-59, and 60 or older).
- To assess the numbers of persons with episodic Migraine in the US, researchers applied age and gender stratified estimates of Migraine prevalence to the 2015 Census data.
- To estimate the number of cardiovascular events, conditions, and procedures in the US Migraine population, we applied age and gender stratified event rates to the number of persons with episodic Migraine in each stratum."
The 2009 AMPP Study survey was returned by 11,792 study participants out of 16,983 (64.9% response rate), including 6,723 individuals who met study criteria for episodic Migraine (5,227 women and 1,496 men).
Among 22-39 year olds with episodic Migraine:
- 3.4 percent reported having received a physician diagnosis of CV events or conditions
- 1.1 percent reported undergoing CV related procedures.
Among 40-59 year olds:
- 10.2 percent reported having received a physician diagnosis of CV
events or conditions
- 3.5 percent reported CV related procedures.
- 10.2 percent reported having received a physician diagnosis of CV
For those age 60 or older:
- 22.3 percent reported CV events or conditions
8.8% reported CV procedures.
Prevalence of events, conditions, and procedures was higher in men than women and in older age groups.
The absolute number of CV events, procedures, and conditions was greater for women than men due to the higher population prevalence of episodic Migraine in women.
A projected 2.0 million women and 665,000 men in the United States had episodic Migraine and a history of one or more CV event, condition, or procedure.
By age group, researchers estimated the number of people in the United States with episodic Migraine who had ever had at least one CV event, procedure, or condition to be:
- 579,000 among those aged 22-39
- 1.37 million of those aged 40-59
- 696,000 of those 60 and older
"Based on these analyses, we estimate that there are roughly 2.6 million people with episodic Migraine aged 22 and older in the US with one or more prior CV event, condition, or procedure. For this group, cardiovascular contraindications to many Migraine-specific acute Migraine therapies may make treatment challenging."1
"Migraine itself is associated with cardiovascular risk. In addition several common and effective medications for migraine management carry cardiovascular risks including triptans, ergot alkaloids and NSAIDs. We do not want the findings of our study to alarm people with migraine; however, we do want them to be aware that if they have had a cardiovascular event, procedure or have a cardiovascular condition they should share this information with their healthcare professional and together carefully choose treatment options which would not put them at additional cardiovascular risk. In addition, people who have not had a cardiovascular event but have certain risk factors such as obesity or smoking should also work with their healthcare professional to find the safest treatment options. In addition to pharmacologic treatments, they may also want to consider options such as behavioral treatments, neurostimulation and interventional treatments which do not carry cardiovascular risk."1
Comments from study author:
Dawn Buse, Ph.D., commented:2
"A personalized, optimized treatment plan should be developed through collaboration and communication with your healthcare professional.
"Healthcare professionals treating patients for migraine should screen for cardiovascular risk before prescribing these therapies. Primary care clinicians should also reassess patients’ cardiovascular health over time. As a patient ages, cardiovascular risk is likely to increase. Triptans that may have been safe when first prescribed may become unsafe with advancing age and age related risk factors for cardiovascular disease including hypertension, diabetes and high cholesterol may develop. Finally, primary care clinicians should remain vigilant to cardiovascular risks in women as well as men. Cardiovascular disease is both under-recognized and undertreated in women; however, cardiovascular disease is the leading cause of death in women and almost one in five women have migraine."
"Novel migraine specific therapeutics are in development which do not carry cardiovascular risk which are also not narcotics. Candidate treatments in development target 5HT1F (serotonin) or CGRP receptors. In addition, empirically supported behavioral and interventional approaches such as nerve blocks, biofeedback and cognitive behavioral therapy have strong evidence for their use either alone or in conjunction with acute pharmacotherapy without cardiovascular liability."
Comments and implications for patients:
Over the years, we've seen quite a bit of information about links between Migraine and cardiovascular conditions such as heart attack and stroke. We've seen data that says Migraine increases the risk of such events. There's also been quite a bit of discussion about Migraine abortive medications such as triptans and ergotamines being unsafe for Migraine patients with a history of or high risk factors for these conditions. What we haven't see is any real numbers showing how many people with Migraine have cardiovascular disease, events, or procedures. Finally, this study illuminates us with real numbers.
This study also recognizes and points out the real-life treatment challenges many of us face, reiterates the limitations of current acute treatments for Migraine, and offers valuable perspective on the situation. The study conclusions offer valuable advice to patients who need to discuss the issues of medication safety with their doctors. The comments Dr. Buse offered in our interview are well considered and offer hope for safer treatments from medications currently in development.
More helpful articles:
1 Buse D, Reed M, Fanning K, et al. Cardiovascular Events, Conditions, and Procedures Among People With Episodic Migraine in the US Population: Results from the American Migraine Prevalence and Prevention (AMPP) Study. Headache 2017;57: 31–44.
2 Email interview with Dawn Buse, Ph.D. February 20, 2017.