by Dr. Awss Zidan
In this series of posts, I tackle some of the most frustrating mistakes physicians fall into when managing migraine patients. If you have not done so already, make sure you visit the previous article here for myth #1.
Myth #2
"Triptans are contraindication because your migraine aura is....."
Triptans are some of the most effective rescue therapy for people with migraines. Since they came out in 1991, triptans have changed thMistakes in Managing Migraine (Part 2) The Triptan Avoidantse life of many migrainours.
All triptans work in a similar mechanism; they support the role of serotonin in certain parts of the brain. Now, the issue is that serotonin has many functions in the brain and other organs; and one of these functions is constricting the small arteries. This is the same mechanism that our platelets utilize to reduce blood flow over an open wound so they get the chance to clump and form a clot.
Before I was even in medical school, there was a popular theory in how migraines occur; called the vascular theory. According to this theory, migraines begin because of a serotonin dump causing narrowing of the arteries. When serotonin is exhausted, the arteries dilate and then they start causing pain as the blood rushes through these "primed" dilated arteries. This theory explained why some people get auras, which are stroke like symptoms (visual changes, tingling and numbness, weakness, difficulty with speech...etc) before they have their migraines, and it also explained why some patients feel their heart beats, or see the dilated veins in their temples while having an attack.
Many years later, this theory is completely refuted. We consider it a "cute" attempt to understanding migraine, which is a much more complex disease as we know now. For example, it is clear now that migraine pain has nothing to do with dilated arteries, and that some patients will not have any dilatation and still have pain; and that triptans effect on managing migraine pain has nothing to do with its effects on the blood vessel, which is mild in any case.
However, one sequela of this theory that has never disappeared is that it caused triptans to be contraindicated in patients with certain types of auras as it was felt that auras were similar to strokes, and that triptans would increase the risk of having a stroke because of vessel narrowing. This is especially applied when the aura is not only visual changes, but rather a complex constellation of symptoms like tingling, vertigo and/or weakness (collectively called brainstem auras)
The thing is this was never found to be the case. There is not a single good quality study to my knowledge that showed triptans increased the risk of stroke in patients with aura. In reality, there are plenty of studies (referenced below) that showed exactly the opposite, which is that triptans did not cause any strokes in patients who had auras or any type.
More over, physicians took liberty into interpreting what constitutes a contraindication for triptans. So instead of limiting their use to patients who have clear stroke-like auras such as one-sided weakness, they started applying it to very common scenarios, such as having tingling and numbness, or vertigo in association with migraine. Having such symptoms is an extremely common thing in migraine, and preventing these patients from taking triptans does them wrong.
I have seen a handful of patients so far whose lives were forever changed after I allowed them to use triptans which they were prohibited from using before.
As always, this is not a medical advice for your specific case, but only for education, so you can carry a more informed discussion with your physician.
References:
1) Klapper, J., N. Mathew, and R. Nett. "Triptans in the treatment of basilar migraine and migraine with prolonged aura." Headache: The Journal of Head and Face Pain 41.10 (2001): 981-984.
2) Artto, Ville, et al. "Treatment of hemiplegic migraine with triptans." European journal of neurology 14.9 (2007): 1053-1056.
3) Mathew, Paul G., et al. "A retrospective analysis of triptan and dhe use for basilar and hemiplegic migraine." Headache: The Journal of Head and Face Pain 56.5 (2016): 841-848.
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