Review of Treatment Strategies for Successful Migraine Management: Adverse Events
Because of initial findings of cardiovascular adverse events in the initial generic sumatriptan trials and in the postmarketing surveillance studies, all trip-tans carry a drug-class warning. The use of triptans is contraindicated in patients with ischemic heart disease, Prinzmetal angina, uncontrolled high blood pressure, and prior history of cerebrovascular accident. Moreover, the concomitant use of triptans and ergot-containing products within 24 hours is contraindicated because of additive vasoconstrictive effects. Triptans should also be avoided in patients with risk factors for cardiovascular disease, such as postmenopausal females, males older than 40 years, family history of heart disease, cigarette smokers, and those with hypertension or diabetes mellitus.
All triptans cause vasoconstriction in the cerebral circulation and might cause a similar effect on coronary arteries. Numerous electrocardiograms (ECGs) were completed during reports of chest pain; no study to date showed abnormalities in ECG pattern. As a drug class, the triptans are efficacious and well-tolerated. The vasoconstrictive effects of the triptans are worrisome; however, this action also lends a therapeutic value. The chest symptoms (pain, pressure) are associated with all the triptans, but they are more commonly reported with parenteral sumatriptan. This effect might be caused by higher bioavailability and faster onset of action. A recent report by Foster et al. suggests that chest pain reported with sumatriptan might be caused by alteration in esophageal motor function. During this study, no ECG abnormalities were observed. Nonetheless, further evaluation is still needed, and the use of triptans in patients with cardiovascular risk factors or disease is contraindicated.
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The safety and tolerability data thus far for almotriptan are favorable. The most common adverse events reported in less than 3% of patients in the almotriptan trials included dizziness, nausea, headache, somnolence, and paresthesia. At the recommended therapeutic dose of 12.5 mg, the incidence of adverse events was not statistically different from placebo. The incidence of cardiovascular adverse events, specifically chest symptoms, was 0.2% in phase III trials; other symptoms, such as chest pressure, palpitations, and vasodilation, were not reported. The incidence of adverse events did not change over time with repeated dosing and was not different from the single-dose studies.
Various cardiovascular events have been reported with sumatriptan, including coronary spasm with angina, myocardial infarction, and ventricular fibrillation. Thus, a blanket cautionary statement is issued with all 5-HT1B/1D agonists regarding their use in head-pain patients with cardiovascular disease, silent ischemic disease, or multiple risk factors. It is important to note that differences in tolerability might exist among the various agents; however, in vitro coronary activity is essentially the same.
CONCLUSION
A multimodal approach to the treatment of the migraine patient is necessary to achieve the most successful outcomes. Our understanding of the pathophysiology and treatment of migraine headache was revolutionized with the availability of sumatriptan canadian and other triptans that followed. As a consequence, numerous pharmacologic agents are now available for acute and preventive treatments for these patients. Studies have shown that successful treatment must include an agent that is fast-acting, provides them with significant improvement in pain relief or totally abolishes their pain, has a low adverse-effect profile, decreases the incidence of migraine recurrence, and is cost-effective. No agent available has all of the characteristics of an ideal agent and so the quest is ongoing. The newly published evidence-based guidelines help guide our treatment strategy now that the level of efficacy of the various pharmacological agents is better defined. Early evidence suggests that treatment should be initiated early during a migraine attack, with migraine- specific therapies such as the triptans or ergot derivatives. Treatment strategies might shift in the coming months, but nonetheless, there are many tools available for use in various treatment strategies for migraine patients today.
