Does starting a triptan for migraine increase the risk of stroke or myocardial infarction?

Product labelling specifies that triptans (e.g., sumatriptan, rizatriptan) are contraindicated in patients with ischemic heart disease or previous myocardial infarction due to concerns that their vasoconstrictive properties can lead to ischemic vascular events. Caution is also advised when prescribing these drugs to patients with vascular risk factors. Controlled observational studies, however, have shown either no association between triptans and ischemic events or an apparent lower risk, possibly due to channeling of triptan use to individuals at low risk of cardiovascular outcomes.To establish whether an association exists between triptans and ischemic events, a new study has examined the occurrence of ischemic events in patients starting on a triptan. The study, conducted from January 1995 to August 2022, included all people in a nationwide Danish registry who were initiating triptans for the first time. A case-crossover design was used to estimate odds ratios (ORs) for associations between first-ever triptan use and ischemic outcomes. For each person, triptan exposure was compared in the two-week period before the ischemic event and with four two-week reference periods. All people in Denmark who filled a prescription for any triptan and experienced at least one of three predefined ischemic outcomes (acute myocardial infarction, ischemic stroke or nonspecified stroke) were included in the study.Results showed the following:The study included 429,612 individuals (median age 38 years; 75.8% female) who redeemed a first prescription for a triptan.Of these patients, 11 (0.003%) had a myocardial infarction with the first triptan prescription (OR, 3.3; 95% CI, 1.0–10.9). The association with myocardial infarction was strongest in patients younger than 60 years and in those with previous acute coronary syndrome.18 patients (0.004%) had ischemic stroke with the first triptan prescription (OR, 3.2; 95% CI, 1.3–8.1). The association with ischemic stroke was strongest in men and in patients younger than 60 years.35 patients (0.008%) had ischemic/nonspecified stroke with the first triptan prescription (OR, 3.0; 95% CI, 1.5–5.9). Overall, patients who developed an ischemic event had a median age of approximately 60 years and had a high-risk cardiovascular profile. These results suggest that triptan initiation is associated with higher risk of ischemic stroke and myocardial infarction. The authors conclude that their results support current recommendations to avoid triptans in patients with a history of coronary artery disease, transient ischemic attack or stroke. However, for patients with low cardiovascular risk, the risk of an ischemic event after starting a triptan initiation is very low and there should be no concerns about triptan use in these individuals. Reference1. Petersen CL, Hougaard A, Gaist D, et al. Risk of stroke and myocardial infarction among initiators of triptans. JAMA Neurol 2024; published online February 5, 2024. (accessed February 6, 2024).

Does starting a triptan for migraine increase the risk of stroke or myocardial infarction?

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