Original Article: Acute Migraine Headache: Treatment Strategies

Issue Date: February 15, 2018

See additional reader comments at: https://www.aafp.org/afp/2018/0215/p243.html

To the Editor: We would like to thank Drs. Mayans and Walling for their review of the treatment of acute migraine headaches, for which triptans are a first-line pharmacologic option. In Table 5, eletriptan (Relpax) is described as the triptan class agent with the least cardiovascular risk. Because patients who are candidates for pharmacotherapy may have cardiovascular risk factors or cardiovascular disease, we will review the literature on this risk assessment.

Because triptans antagonize 5-hydroxytriptamine receptors expressed in the cerebrovascular and coronary vessels, triptans as a class are associated with cardiovascular and cerebrovascular risks related to vessel vasoconstriction. Contraindications to triptans include, but are not limited to, peripheral vascular disease, coronary artery disease, cerebrovascular disease, and uncontrolled hypertension. A 2004 American Headache Society consensus statement noted that the cardiovascular risk for triptans is relatively small, with fewer than one adverse cardiovascular event per 1 million patients exposed.¹

Eletriptan is a selective 5-hydroxytriptamine receptor 1B/1D antagonist and is approved by the U.S. Food and Drug Administration for the acute treatment of migraine with or without aura in adults. It has been described as more selective for intracranial blood vessels, inducing less contraction in coronary tissues in vitro compared with sumatriptan (Imitrex).² Notably, another Letter to the Editor emphasized that this study's conclusion is misleading and that all triptans have similar effects on vasoconstriction.³ In a single group study of 10 patients without coronary artery disease who received intravenous eletriptan (80 mg over 30 minutes) after a placebo infusion of normal saline over 10 minutes, eletriptan showed no significant effects on constriction of the coronary arteries, as demonstrated by angiography at regular intervals of infusion.⁴ However, this theoretical, comparative benefit has not been demonstrated in studies reporting cardiovascular outcomes.

In summary, the proposed lower cardiovascular risk of eletriptan is based on a challenged in vitro study and a small study of intravenous eletriptan (not used in practice) in humans without coronary artery disease. Because triptans as a class have relatively small cardiovascular risk in patients without coronary artery disease, selection is best supported by the clinician's assessment of effectiveness, safety, pharmacokinetics, availability, and insurance coverage.