New Analysis of Triptan and DHE Use in Basilar and Hemiplegic Migraine

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One of the biggest frustrations migraine patients face is finding effective treatments. This is especially the case for those who suffer from hemiplegic migraines, a rare type of migraine in which patients can experience partial paralysis on one side of their body. The same also goes for migraines that originate in the lower brain and brainstem, otherwise known as basilar-type migraines.

For these patients, popular treatments such as triptan pills and dihydroergotamine medications, which are injected or administered as a nasal spray, are considered to be off-limits due to a presumed higher risk for ischemic vascular events, where normal blood flow is restricted by the buildup of plaque in the arteries. The Food and Drug Administration has even mandated that pharmaceutical companies include a warning in the label.

Now a new retrospective analysis published in the journal Headache has presented findings that puts this widely-held assumption under question.

The Study

Background:

"Patients with basilar migraine (BM) and hemiplegic migraine (HM) have been excluded from triptan and DHE clinical trials due to a potential risk of ischemic vascular events, and the FDA mandates that package labeling state that they are contraindicated in BM (migraine with brainstem aura) and HM (hemiplegic migraine). The objective of this study was to demonstrate that triptans and DHE can be used for the abortive treatment of BM and HM without significant adverse ischemic vascular events."1

Research Methods:

  • The retrospective chart review looked at patients who had suffered from BM or HM.
  • Patients were diagnosed with either BM or HM by migraine specialists under criteria laid out by the International Classification of Headache Disorders.
  • Patients received triptan or dihydroergotamine treatments to relieve their migraines.
  • Patients were treated at one of four headache centers.

Results:

  • The analysis included 67 patients with BM and 13 patients with HM.
  • Among those receiving triptan treatment, 40 were in the BM, and five were in the HM group.
  • Among those receiving DHE treatment, 27 were included in the BM group and eight were in the HM group.
  • There were no reported instances of patients experiencing a stroke or heart attack as a side effect.
  • In the triptan treatment group, five patients reported adverse side effects that included upset stomach, rash, nightmares, flushing and neck dystonia, where muscles along the neck contract uncontrollably.
  • In the DHE treatment group, five patients experienced side effects that included chest tightness, agitation, involuntary spasms known as a dystonic reaction and transient asymptomatic anterior T wave inversion.

Conclusion:

"In this retrospective study, triptans and DHE were used with no reported, subsequent acute/subacute ischemic vascular events for the abortive treatment of migraines with basilar and hemiplegic-type features. Although the small sample sizes generated theoretical statistical event rates of 4.5 percent for BM and 23 percent for HM, there has been no clear evidence that BM and HM carry an actual elevated risk for vascular events compared with migraine with aura."1

Clinical Implications:

  • "Triptans and DHE were used effectively without any subsequent ischemic vascular events for the abortive treatment of migraine with brainstem aura and hemiplegic type features."1
  • "Renaming of BM in the ICHD-3-beta version to migraine with brainstem aura is better in that the name no longer implies basilar artery vasoconstriction."1

Implications for Patients and Doctors:

  • These results lend support to some of the researchers’ previous work. In 2014, Mathew, Spinner, and Joshi reached a similar conclusion and during their presentation at the annual scientific meeting of the American Headache Society stated:
  • "In this retrospective study, triptans were used effectively with no subsequent vascular events for the abortive treatment of migraines with basilar and hemiplegic features. This data also suggests that beta blockers, tricyclic anti-depressants, anticonvulsants, and Botox injections have some efficacy in the treatment of migraines with basilar type and hemiplegic features."2
  • The group’s findings also reflect an ongoing rethinking of the kind of underlying changes that the brain and the nervous system go through when a migraine strikes. And with recent evidence suggesting that changes in blood flow are not needed for a migraine to occur and that they don't always occur, the reasons why triptan and DHE have been considered contraindicated are now being called into question. Consequently, this could lead to triptans and ergotamines playing a bigger role in the treatment of BM and HM.
  • Of course, proper precautions need to be taken. Patients and doctors shouldn’t simply disregard the contraindication of triptan and dihydroergotamine medications when used for the treatment of BM and HM.
  • For hemiplegic and basiler-type migraine patients who struggle with finding relief, it may be worth discussing these popular options with their doctors.

Resources:

1 Mathew, Paul G., MD, FAHS; Krel, Regina, MD; Buddhdev, Bhuvin, MD; Ansari, Hossein, MD; Joshi, Shivang G., MD, MPH; Spinner, Warren D., DO; Klein, Brad C., MD, MBA. "A Retrospective Analysis of Triptan and DHE Use for Basilar and Hemiplegic Migraine." Headache. Early View. First published online April 8, 2016.

2 Krel, R.; Mathew, P.G.; Spinner, D.; Joshi, S. "Spinning Out of Control: The Black Box of Basilar and Hemiplegic Migraine." Poster Presentation. 56th Annual Scientific Meeting; American Headache Society. Los Angeles. June, 2014.