Are triptans safe as an acute treatment for hemiplegic migraine?
Triptans are contraindicated in patients with hemiplegic migraine. However, if someone with hemiplegic migraine also has typical migraine attacks, triptans can be used for the acute treatment of those attacks.
“Acutely, yes, triptans are contraindicated in patients with hemiplegic migraine. That's based on an old hypothesis that the aura, which is the weakness, is due to a lack of blood supply to the brain, and triptans can cause constriction of blood vessels.
“So back in the day when we first started testing triptans, we would never include a patient with hemiplegic migraine in the trial. Now, we don't believe that aura and the weakness is caused by a lack of blood supply. It's an event in the brain. It's an electrical event in the brain.
“We really don't know if triptans are safe, but they're contraindicated. Which means that if you look, the FDA says that you shouldn't be using these in patients with hemiplegic migraine. I should say the patients with hemiplegic migraine also have typical migraine attacks. So you could use, for example, a triptan, for the headache in nonhemiplegic attacks. But if the patient is weak and then, typically, we would not use a triptan.
“There's a debate about that, some experts… and there's a publication suggesting that in 70-plus patients, they seem to be effective and well-tolerated and it didn't lead to a stroke or any complications, except in one patient where the weakness lasted a few months. But by and large, it's best to avoid the triptans in those patients until we have more evidence and data to suggest that they're safe.”
Triptans are contraindicated in patients with hemiplegic migraine due to an electrical event that occurs in the brain during hemiplegic migraine attacks. However, if those with hemiplegic migraine also have typical migraine attacks, triptans can be used as an acute treatment for those attacks. There is still a debate about the safety of triptan use for those with hemiplegic migraine, but until more data suggests that they are safe, it is recommended to avoid triptans for hemiplegic attacks.
David Dodick, MD
Mayo Clinic, Arizona
David Dodick, M.D., FAAN, is a professor of neurology at the Mayo Clinic College of Medicine and Science in Scottsdale, Arizona. He is the director of the headache program and the sports neurology and concussion program at Mayo Clinic in Arizona. He is an adjunct professor in the department of neurosciences, Norwegian University of Science and Technology. Dr. Dodick is board certified by the Royal College of Physicians and Surgeons of Canada and the American Board of Psychiatry and Neurology (ABPN). He also holds United Council for Neurologic Subspecialties certification in headache medicine and ABPN certification in vascular neurology.
Dr. Dodick has authored more than 380 peer-reviewed publications and authored/edited 10 books. He is the chair of the American Migraine Foundation, chair of the American Academy of Neurology (AAN) Annual Program Concussion Committee, co-director of the American Registry of Migraine Research, chair of the International Registry for Migraine Research, chair of the International Headache Society Global Patient Advocacy Coalition, co-director of the Annual AAN Sports Concussion Conference, president-elect of the International Concussion Society, immediate past-president of the International Headache Society, former editor-in-chief of Cephalalgia, and past-president of the American Headache Society.