A 32-year-old nonsmoking female migraineur presents to your primary care office seeking more effective abortive treatment for her migraines. She is having one to two headaches per month that are only partially relieved by NSAIDs. Each headache lasts 2 to 3 days and negatively impacts her ability to work and to care for her two children. She is currently asymptomatic. Her medical history is negative for diabetes mellitus, hypertension, and dyslipidemia. Her family history is positive for migraine headaches and negative for cerebrovascular and coronary artery disease. Medications include NSAIDs as needed and amitriptyline, which has been an effective prophylactic agent for her. She does not take oral contraceptives. At this time, results of a physical examination are normal.
Chart review reveals that this patient's typical migraine manifests with a visual aura followed by left arm paresthesias. The aura resolves in less than an hour and is followed by the onset of unilateral throbbing pain, photophobia, phonophobia, nausea, and vomiting. There is hyperesthesia in the left hand, but the findings on physical examination are otherwise normal. The patient has undergone multiple cranial imaging studies that have all been without significant findings. Based on the above symptomatology, typical aura-type migraine headache is diagnosed using the second edition of The International Classification of Headache Disorders.1 You consider initiating therapy with a triptan for abortive treatment, but you are hesistant because of concern that triptan therapy may predispose a patient with prominent aura symptoms to having a stroke.
Clinical question
Do triptans increase the risk of thromboembolic stroke in female, nonsmoking patients with migraine who do not have other risk factors for stroke?
Search criteria and results
The data sources searched for this article include MEDLINE (1966 to January 2005), EMBASE (1980 to 2005), and Cochrane Collection's CENTRAL. The search is considered up-to-date through January 2005. Inclusion criteria were randomized controlled trials, prospective comparative studies, retrospective case-control studies, and retrospective cohort studies that directly studied the rate of stroke associated with triptan use. Each data source was searched using the search terms
cerebrovascular accident AND triptan.
A total of eight unique articles were identified using this search strategy. To ensure articles were not being omitted, a secondary search strategy utilizing the search terms migraine with the therapy subheading AND cerebrovascular accident was conducted. The secondary search strategy did not identify any new articles that addressed the question. Further searching of Cochrane Collection Reviews and Bandolier yielded no secondary review articles pertinent to the question. Of the eight unique articles identified, only two articles— those by Hall and colleagues
2 and by Velentgas and colleagues
3 — were deemed to meet the initial inclusion criteria. Both articles are retrospective cohort studies written by coauthors who have received support from Pfizer Inc. without restriction on publication or currently are employed by Pfizer.
2,3