Migraine Management: The Options and the Obstacles
April 24, 2000 -- They may be the most effective drugs ever created for
treating migraine headaches, but the triptans have proven a hard sell to some
patients. Ronda Solberg, who runs a web site devoted to migraine sufferers,
says one of the drugs -- sumatriptan -- didn't work for her, and she says that
some visitors to her page have expressed concern about an increased risk of
stroke or heart problems with the drugs.
But one expert says there's absolutely nothing to worry about. "The
drugs are safe and effective, and they work for most people," says Stephen
D. Silberstein, MD, co-chairman of the U.S. Headache Consortium and director of
the Headache Center at Thomas Jefferson University Hospital in Philadelphia.
"I think it's safer to take a triptan than a non-steroidal
anti-inflammatory [Advil, for example] -- if you look at what drug class winds
people up in the hospital," he tells WebMD.
What is a triptan and how did they get such a mixed reputation? They are
drugs with a makeup similar to a natural substance in the human brain,
serotonin. When taken at the right time, triptans can stop a migraine headache
from getting worse. The drugs may work, in part, by causing blood vessels in
the brain to contract -- an effect the drugs can also induce elsewhere in the
body. And that's what has led to concern about side effects in the heart.
"One of the first adverse reaction reports with the triptans was a
general chest pain," says Jean-Michal Jries, PharmD, PhD, of the American
Society for Clinical Pharmacology and Therapeutics. While the chest pain does
not always mean a problem with the heart, heart patients are usually steered
away from the triptans.
"If someone has severe heart problems, should they stay away from
triptans? Yes," says Michael John Coleman, executive director of MAGNUM/The
National Migraine Association in Washington, D.C. "But we do see a lot of
triptan bashing -- PPOs and HMOs trying to generate a lot of fear about
In fact, Coleman says his organization has collected about a thousand
complaints over the last two years about insurers trying to limit use of the
triptans, not because of heart risks, but due to what he says is an erroneous
belief that they cause "rebound headaches" (as well as, he believes,
their high cost.) "Rebound headache" is a phenomenon where headaches
become more frequent after taking certain medications, and physicians aren't
sure why it happens. "There is no triptan rebound," Coleman says.
"Rebound headache is a significant problem, and it's caused by misuse of
over-the-counter medications and ergot alkaloids [another type of migraine
treatment], particularly the older ones."
As well as they work, the triptans are not for everyone. Silberstein says
some migraine patients only get relief from that older and cheaper class of
drugs, the ergot alkaloids. These compounds, derived from a fungus on rye,
cause intense constriction of blood vessels -- so much so that misuse can cause
tissue in the fingers and toes to die and become infected -- a condition called
gangrene. Coleman suffered just such a side effect on his left foot because of
ergot overuse as a child.