PHILADELPHIA—It is time to reevaluate the objection to triptans in the treatment of migraine complicated by neurologic symptoms, asserted Ninan T. Mathew, MD, Director of the Houston Headache Clinic. In an observational study of 24 patients with complicated migraine, Dr. Mathew found that triptans did not worsen neurologic symptoms. They improved them, and they provided effective pain relief.

Clinician resistance to this treatment strategy grew out of the belief that the neurologic symptoms of migraine result from ischemia and would therefore be worsened by the vasoconstriction triptans produce. However, mounting evidence strongly suggests that these symptoms are primarily neuronal in nature. “If that is true,” Dr. Mathew said at the 53rd Annual Meeting of the American Academy of Neurology, “triptans should not be contraindicated [in complicated migraine].”

EARLY INTERVENTION EMPHASIZED

Twenty-four patients with complicated migraine referred to the Houston Headache Clinic made up the cohort for this observational study. Exclusion criteria were aura without headache, evidence or a history of collagen vascular disorders, a high risk for occlusive vascular disease, and the presence of anticardiolipin antibodies. Diagnostic testing in all cases consisted of magnetic resonance imaging, magnetic imaging angiography, magnetic resonance venography, electroencephalogram, and electrocardiogram. Four patients also had conventional arteriograms.

Migraine was basilar in 11 patients and hemiparetic in four. Three patients had familial migraine with complex neurologic symptoms (ataxia, hemiparesis, speech abnormalities, deafness), three patients had dysphasia, and three patients had extracephalic cutaneous allodynia during migraine attacks. Because 10 of the patients had previous exposure to triptans, they were referred for a second opinion to verify the safety of further treatment. Triptan therapy was initiated by the authors in the remaining patients.

“Early intervention was emphasized,” said Dr. Mathew. The patients were instructed to take an oral triptan—sumatriptan, zolmitriptan, rizatriptan, or naratriptan—as early as possible in a migraine attack, even if neurologic symptoms were present.

REDUCED NEUROLOGIC SYMPTOMS, GOOD EFFICACY

A total of 59 migraine episodes were treated. At the time of triptan dosing, in 49 of the episodes the head pains were mild, 14 were moderate, and four were severe. Neurologic symptoms accompanied 51 migraine attacks.

“No patient showed worsening of neurologic symptoms or developed any new neurologic symptoms when they were on triptans,” stressed Dr. Mathew. More than half reported that triptan use reduced the duration of these symptoms, which lasted an average of 4.2 hours before treatment but only 1.5 hours after. Triptans also reduced neurologic symptom severity and completely prevented cutaneous allodynia in the three patients with that symptom.

The triptans showed good efficacy, with more than half the patients who received them reporting that they were free of pain at two hours. Efficacy was slightly better with rizatriptan and naratriptan. Drowsiness and other side effects were uncommon.

Currently, Dr. Mathew pointed out, patients with complicated migraine often end up receiving very large quantities of opioids or other suboptimal therapies with very poor results. While the small size of the study conducted by Dr. Mathew and colleagues limits the strength of its findings, it provides compelling evidence in support of early triptan use as a potent and effective alternate to these less effective therapies and suggests a line for further, more widely scaled research into the treatment of this affliction.

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