Older Adults Using Triptans for Migraines May Have Low Increased Stroke Risk

Older adults prescribed second-generation serotonin 5HT1B/1D-receptor agonists (triptans) for migraines may be at a low increased risk for stroke, according to study findings published in The Journal of Headache and Pain.

While several studies have evaluated the association between triptans and acute vascular events, this relationship remains unclear and has not been studied in a target population of older adults. Researchers conducted a study to determine if this risk is prevalent among patients aged 65 and older. 

The researchers collected data from a French national electronic database called the Systeme National de Données de Santé (SNDS). Participants who picked up their first triptan prescription between July 1, 2011, and June 30, 2014, were considered for inclusion and defined as new users. Those prescribed subcutaneous sumatriptan or ergot alkaloids and triptans were excluded from the study. 

The analysis was conducted in 2 phases: a propensity score-matched cohort study to compare cardiovascular outcomes and death due to triptan exposure and a complementary analysis to address residual confounding factors. The initial phase was conducted among the triptan users and matched control group participants, and the second phase was conducted using the triptan users as their own controls, allowing for self-adjusting over time. The secondary analysis included a case-crossover (CCO) design and a self-controlled case-series (SCCS). 

The primary outcome was acute ischemic vascular events, which was defined by a hospital admission with a main diagnosis based on the International Classification of Diseases, 10^th revision (ICD) codes within 90 days of the index date.  

A total of 47,353 participants who used triptans and 189,412 control group participants were initially included in the study, with an average age of 71 and 71% women participants. The propensity score-matched cohort included 24,774 participants in the triptan group and 99,096 in the control group, with similar baseline characteristics to the initial cohort. 

Among these participants, 163 (0.66%) cardiovascular (CV) events were reported in the triptan group compared to 523 (0.53%) in the control group within 90 days after the index date. The Cox regression model revealed an adjusted hazard ratio (aHR) of 1.25 (95% CI, 1.05-1.49) and the time-varying analysis was conducted to show exposure at the time of the event reported an aHR of 8.74 (95% CI, 5.21-14.66). 

The CCO study with 299 patients showed that triptan exposure had a significant association for all ischemic events (adjusted odds ratio [aOR], 1.63; 95% CI, 1.22-2.19), specifically for cerebral events (aOR, 2.14; 95% CI, 1.26-3.63) and not cardiac events.

The SCCS study was conducted with 1804 patients who had a mean observation period of 3.42 years and mean triptan exposure of 44.15 days. The relative incidence (RI) for all ischemic events was 2.13 (95% CI, 1.76-2.58) based on the standard method and 3.53 (95% CI, 2.89-4.31) based on the pseudo-likelihood method. The RI for cardiac events was 1.67 (95% CI, 1.23-2.27) and for cerebral events was 3.20 (95% CI, 2.30-4.45).

Study limitations included using triptan dispensing as a proxy for migraine, lack of cardiovascular risk data, and residual misclassification. 

“Migraine treatment in the older population requires careful consideration of increased medical comorbidities,” the researchers concluded. “Unfortunately, for most migraine drugs, both for acute and preventive treatment, efficacy studies are lacking for patients ≥ 65 years.”