Even with optimal therapy, many patients with migraine obtain only partial relief and could benefit from prophylactic therapy. The long-term use of common prophylactic agents, such as beta blockers, valproate and nonsteroidal anti-inflammatory drugs, is limited by adverse effects. This situation has prompted the search for new agents to reduce the number and severity of migraine attacks. Based on observational and anecdotal evidence, patients taking lisinopril for hypertension were believed to have fewer migraine attacks. Schrader and colleagues conducted a randomized, placebo-controlled, crossover study to examine the prophylactic effect of lisinopril on migraine.
Participants 18 to 60 years of age who met International Headache Society criteria for migraine were recruited from an outpatient clinic and through local newspaper advertising. Participants had to report having two to six migraine episodes per month for at least one year beginning before the age of 50. Exclusion criteria included use of prophylactic medications, pregnancy or lack of contraception, decreased hepatic or renal function, or contraindication to the study medication.
All participants kept a symptom diary for a four-week placebo run-in period to establish the number and characteristics of migraine attacks. The 60 participants were then randomly assigned to treatment with lisinopril or an identical placebo for 12 weeks. Participants treated with lisinopril were given one 10-mg dose per day for one week, then two 10-mg doses per day for 11 weeks. Participants treated with placebo followed a similar regimen. Following a second placebo “wash-out” period of two weeks, the treatments were reversed for each patient for an additional 12 weeks. Throughout the study, participants kept a daily symptom diary and completed a quality-of-life questionnaire. Outcomes measured included the number of days and hours of headache, headache severity, use of medications and time lost from work. Participants were also asked about the acceptability of treatment.
Data were complete on 38 women and nine men. The main reason for not completing the study was noncompliance. Only three participants withdrew because of side effects. During lisinopril therapy, 24 of 60 participants reported an adverse effect. The principal adverse effect was cough, which was reported by eight participants during lisinopril therapy and three during placebo therapy. Other adverse effects included dizziness in seven participants taking lisinopril and four participants taking placebo, and fatigue in three participants during both therapies. During placebo periods, mean blood pressure was 128/83 mm Hg and mean pulse was 71 beats per minute. During lisinopril therapy, the corresponding figures were 121/78 mm Hg and 69 beats per minute. While taking lisinopril, participants reported a reduction in body pain, but otherwise the health and quality-of-life scores were comparable during both treatment periods.
The number of hours and days with headache was significantly reduced during lisinopril treatment (see accompanying table). About one third of participants reported at least a 50 percent reduction in symptoms, number of days with migraine and severity of attacks.
The authors conclude that lisinopril has a clinically significant prophylactic effect in migraine. This could be caused by several mechanisms, including altered sympathetic activity, inhibition of free radical activity, increased prostacyclin synthesis and alteration of the metabolism of various neurochemicals. It is also known that migraine without aura is more common in persons with the angiotensin-converting enzyme DD gene and that carriers of this gene have higher angiotensin-converting enzyme activity and more frequent attacks, suggesting a genetic mechanism. Lisinopril is well tolerated and may prove to be a useful prophylactic agent for migraine if the results of this study can be confirmed.
|Lisinopril||Placebo||Mean % reduction (95% CI)|
|Primary efficacy parameter|
|Hours of headache||129 (125)||162 (142)||20 (5 to 36)|
|Days with headache||19.7 (14)||23.7 (11)||17 (5 to 30)|
|Days with migraine||14.5 (11)||18.5 (10)||21 (9 to 34)|
|Secondary efficacy parameter|
|Headache severity index||297 (325)||370 (310)||20 (3 to 37)|
|Triptan doses||15.7 (15)||20.2 (17)||22 (7 to 38)|
|Doses of analgesics||14.5 (23)||16.2 (20)||11(−16 to 37)|
|Days with sick leave||2.30 (4.32)||2.09 (2.50)||−10(−64 to 37)|
|Bodily pain*||63.7 (29)||53.8 (23)||−18 (−35 to −1)|
|General health*||73.6 (20)||74.1 (21)||1 (−6 to 7)|
|Vitality*||61.1 (24)||58.2 (21)||−5(−18 to 8)|
|Social functioning*||81.4 (25)||79.5 (23)||−2(−11 to 6)|