Is there any evidence that sumatriptan might be more associated with an increased risk of stroke th

Fråga: Is there any evidence that sumatriptan might be more associated with an increased risk of stroke than other triptans in young female migraineurs with aura?

A 30 year-old woman states that she cannot use sumatriptan because her neurologist says that sumatriptan is contraindicated in migraine with aura due to the risk of stroke. She is therefore prescribed rizatriptan (Maxalt).

Sammanfattning: Migraine (especially with aura) is associated with an increased risk of stroke. Triptan use has not been associated with an increased risk of stroke when used adequately. Overuse and combination with ergot derivatives should be avoided. There is no reason to believe that any triptan would differ from the others in this respect.

Svar: Stroke prevalence is low in young people. Different studies have estimated the stroke incidence rate in people below 35 years of age to between one and 10/100000. Most studies show a higher incidence rate in women than in men (1). Migraine has been associated with an increased risk of stroke in several epidemiological studies. This association is strongest in women below 35 with migraine with aura. The absolute annual stroke risk has been estimated to 17/100000 in any migraineur and 52/100000 in migraineurs with aura. One study of 308 young (15-44 years of age) patients with stroke or transient ischemic attack (TIA) showed an odds ratio for stroke of 8.6 (1-75) in migraineurs with aura and 3.7 (1.5-9.0) in women below 35 with migraine compared to 591 matched controls (2). Another study of some 3500 patients with ischemic stroke showed a higher prevalence of active migraine in young stroke patients (<45 years) than in older. Twenty-one percent of ischemic strokes in migraineurs was directly associated with a migraine attack (ischemic stroke occurring during an attack of migraine; ISODAM) (3).

One study trying to estimate cardiovascular morbidity and mortality in relation to triptan use (n=13664) in a general practice migraine cohort (n=63575) found a hazard ratio for stroke of about 1.5 in patients with migraine. The risk was greater in patients not treated with a triptan, but on the other hand, patients with increased cardiovascular risk were not prescribed triptans (4). Triptans are contraindicated in patients with known cardio- or cerebrovascular disease (5).

Triptans have been associated with ischemic stroke, but most often after repeated dosage, combined with ergot preparations or oral contraceptives or during stroke-associated headache (6,7,8). There are no comparative studies of triptans on the relative risk of stroke. The manufacturer of sumatriptan has no further information on this subject (9).

To be cautious, triptans should not be taken during the aura. Nothing is gained regarding headache by taking triptans already during the aura (10). Lidegaard O. Decline in cerebral thromboembolism among young women after introduction of low-dose oral contraceptives: an incidence study for the period 1980-1993. Contraception. 1995;52(2):85-92. Carolei A, Marini C, De Matteis G et al. History of migraine and risk of cerebral ischaemia in young adults. Lancet 1996;347:1503-6. Milhaud D, Bogousslavsky J, van Melle G, Liot P. Ischemic stroke and active migraine. Neurology 2001;57:1805-11. Hall GC, Brown MM, Mo J, MacRae KD. Triptans in migraine: the risks of stroke, cardiovascular disease, and death in practice. Neurology 2004;62:563-8. Fass 2006 (www.fass.se) Hedenmalm K. Hjärt-kärlbiverkningar av triptaner vid migrän finns men är sällsynta. 5-HT-receptormedierad extrakraniell vasokonstriktion oftast orsak. Läkartidningen 2000;97(25):3078-84.

Swedis (cited 2006-01-19)
Vijayan N, Peacock JH. Spinal cord infarction during use of zolmitriptan: a case report. Headache 2000;40:57-60.
Ulrika Bungay, GlaxoSmithKline AB, personal communication 2006-02-22

Anonymous. Does sumatriptan cause cerebral infarction? Bull SADRAC. 1996;(65):1-2.