Migraine and angina pectoris by coronary artery spasm

Migraine and risk of premature myocardial infarction and stroke among men and women: A Danish population-based cohort study

BACKGROUND

Migraine carries risk of myocardial infarction (MI) and stroke. The risk of premature MI (i.e., among young adults) and stroke differs between men and women; previous studies indicate that migraine is mainly associated with an increased risk of stroke among young women. The aim of this study was to examine impact of migraine on the risk of premature (age ≤60 years) MI and ischemic/hemorrhagic stroke among men and women.

METHODS AND FINDINGS

Using Danish medical registries, we conducted a nationwide population-based cohort study (1996 to 2018). Redeemed prescriptions for migraine-specific medication were used to identify women with migraine (n = 179,680) and men with migraine (n = 40,757). These individuals were matched on sex, index year, and birth year 1:5 with a random sample of the general population who did not use migraine-specific medication. All individuals were required to be between 18 and 60 years old. Median age was 41.5 years for women and 40.3 years for men. The main outcome measures to assess impact of migraine were absolute risk differences (RDs) and hazard ratios (HRs) with 95% confidence intervals (CIs) of premature MI, ischemic, and hemorrhagic stroke, comparing individuals with migraine to migraine-free individuals of the same sex. HRs were adjusted for age, index year, and comorbidities. The RD of premature MI for those with migraine versus no migraine was 0.3% (95% CI [0.2%, 0.4%]; p < 0.001) for women and 0.3% (95% CI [-0.1%, 0.6%]; p = 0.061) for men. The adjusted HR was 1.22 (95% CI [1.14, 1.31]; p < 0.001) for women and 1.07 (95% CI [0.97, 1.17]; p = 0.164) for men. The RD of premature ischemic stroke for migraine versus no migraine was 0.3% (95% CI [0.2%, 0.4%]; p < 0.001) for women and 0.5% (95% CI [0.1%, 0.8%]; p < 0.001) for men. The adjusted HR was 1.21 (95% CI [1.13, 1.30]; p < 0.001) for women and 1.23 (95% CI [1.10, 1.38]; p < 0.001) for men. The RD of premature hemorrhagic stroke for migraine versus no migraine was 0.1% (95% CI [0.0%, 0.2%]; p = 0.011) for women and -0.1% (95% CI [-0.3%, 0.0%]; p = 0.176) for men. The adjusted HR was 1.13 (95% CI [1.02, 1.24]; p = 0.014) for women and 0.85 (95% CI [0.69, 1.05]; p = 0.131) for men. The main limitation of this study was the risk of misclassification of migraine, which could lead to underestimation of the impact of migraine on each outcome.

CONCLUSIONS

In this study, we observed that migraine was associated with similarly increased risk of premature ischemic stroke among men and women. For premature MI and hemorrhagic stroke, there may be an increased risk associated with migraine only among women.

Evaluation of index of cardiac-electrophysiological balance in patients with subarachnoid hemorrhage

Background

Various electrocardiographic (ECG) changes occur after subarachnoid hemorrhage (SAH). Prolonged QT and corrected QT (QTc) intervals are notable changes. QT, QTc, T peak-to-end T(p-e) intervals, and Tp-e/QTc ratio are used as ventricular arrhythmia indices. In recent publications, the cardiac electrophysiological balance index (ICEB), which provides more information than other ECG parameters (QT, QTc, etc.), is recommended in predicting the risk of ventricular arrhythmia. This study aims to assess ICEB in aneurysmal SAH patients.

Methods

The study included 50 patients diagnosed with aneurysmal SAH and 50 patients diagnosed with hypertension without end-organ damage as the control group. All patients’ Fisher scores and Glasgow Coma Scale (GCS) scores were recorded. Both groups were given 12-lead ECGs. QT, QTc, Tp-e intervals, QRS duration, ICEB (QT/QRS), ICEBc (QTc/QRS), and T(p-e)/QTc values were calculated and analyzed between groups.

Results

Compared to the control group; QT (426,64 ± 14,62 vs. 348,84 ± 12,24 ms, p < 0,001), QTc (456,24 ± 28,84 vs. 392,48 ± 14,36 ms, p < 0,001), Tp-e (84,32 ± 3,46 vs. 70,12 ± 3,12, p < 0,001), Tp-e/QTc (0,185 ± 0,08 vs. 0,178 ± 0,02, p < 0,001), ICEB (4,53 ± 0,78 vs. 3,74 ± 0,28, p < 0,001) and ICEBc (4,86 ± 0,86 vs. 4,21 ± 0,24, p < 0,001) were significantly higher in patients with aneurysmal SAH. QT, QTc and Tp-e interval, Tp-e/QTc ratio, ICEB (QT/QRS) and ICEBc (QTc/QRS) were positively correlated with the Fisher score and were negatively correlated with the GCS. According to linear regression analyses, the ICEBc (QTc/QRS) found to be independently associated with the Fisher score.

Conclusion

The values of the ICEB and ICEBc were significantly increased in patients with aneurysmal SAH. The severity of SAH was positively correlated with the ICEB and ICEBc. The ICEBc (QTc/QRS) independently associated with the Fisher score. This may that SAH suggest may predispose to malignant ventricular arrhythmias.

Evaluation of ventricular repolarization parameters during migraine attacks

AIMS

Migraine is a chronic neurovascular disorder characterized by intermittent episodes of severe headache. Abnormalities in the autonomic nervous system (sympathetic and parasympathetic nervous systems) have been detected during migraine-free periods in patients with migraine. In these patients, disrupted autonomic innervations of the heart and coronary arteries may lead to electrocardiographic changes during a migraine attack. T-wave peak-to-end interval (Tp-e interval) and Tp-e/QT ratio are relatively new markers of ventricular arrhythmogenesis and repolarization heterogeneity. In the present observational study, we investigated the changes in ventricular repolarization during migraine attacks and attack-free periods by performing 12‑lead electrocardiography (ECG).

METHODS

This study included 63 patients (54 [86%] women; mean age: 33.3 ± 9.9 years) with migraine. The QT and corrected QT (QTc) intervals, Tp-e interval, and Tp-e/QT ratio of the patients during migraine attacks and attack-free periods were measured by performing 12‑lead ECG.

RESULTS

The QT and QTc intervals, Tp-e interval, and Tp-e/QT ratio were higher during migraine attacks than during attack-free periods (P < 0.001 for all).

CONCLUSION

These results indicate that migraine attacks are associated with an increase in ventricular repolarization parameters compared with attack-free periods possibly because of the dysregulation of the autonomic nervous system.

Migraine and Coronary Heart Disease Mortality: A Prospective Cohort Study

A recent population-based prospective study reported that in women, migraine with aura (MA), but not migraine without aura (MoA), was associated with increased risk of coronary heart disease events (CHD). We sought to confirm this association in an Australian population-based cohort of older men and women ( n = 2331, aged 49-97 years). We defined MA and MoA from face-to-face interview using International Headache Society criteria. Over a mean 6-year follow-up, 30 women (2.8%) and 30 men (4.4%) without any prior CHD history died from CHD-related causes. In women, a history of MA was associated with a non-significant twofold higher risk of CHD death (age-adjusted relative risk 2.2, 95% confidence interval 0.8, 5.8, P = 0.11), which remained similar after adjustment for cardiovascular risk factors. There were no CHD deaths in men with a history of migraine. Our findings support reports that in women, MA, but not MoA, may be associated with increased risk of CHD.

QTC Dispersion and P-Wave Dispersion during Migraine Attacks

The aim of this study was to investigate increase of QTc dispersion and P-wave dispersion during migraine attacks. Fifty-five patients (16–65 years of age, 49 women, six men) with migraine were included in our study. Heart rate, QTc interval, maximum and minimum QTc interval, QTc dispersion, maximum and minimum P-wave duration and P-wave dispersion were measured from 12-lead ECG recording during migraine attacks and pain-free periods. ECGs were transferred to a personal computer via a scanner and then used for magnification of x400 by Adobe Photoshop software. Maximum QTc interval (454 ± 24 ms vs. 429 ± 23 ms, P < 0.001), QTc interval (443 ± 26 ms vs. 408 ± 22 ms, P <0.001) and QTc dispersion (63 ± 18 ms vs. 43 ± 14 ms, P <0.001) were found significantly higher during migraine attacks compared with pain-free periods. Maximum P-wave duration (107 ± 11 ms vs. 100 ± 11 ms, P <0.001) and P-wave dispersion (45 ± 13 ms vs. 35 ± 13 ms, P <0.001) were found higher during migraine attacks than pain-free periods. We concluded that migraine attacks are associated with increased QTc and P-wave dispersion compared with pain-free periods.

The effect of prophylactic migraine treatment on arterial stiffness

BACKGROUND

Migraine is a common type of primary headache predominantly seen in women. This study aimed to evaluate endothelial function in patients with migraine using pulse wave velocity (PWV).

METHODS

The study included 73 patients with newly diagnosed migraine and 80 healthy subjects. All patients and controls underwent baseline transthoracic echocardiography and PWV measurements. Patients were randomized to three groups to receive propranolol, flunarizine or topiramate, and the measurements were repeated at the end of 1 month.

RESULTS

The newly diagnosed migraine patients and the control group exhibited no differences in baseline clinical characteristics, and the measurements showed that PWV was 7.4 ± 1.0 m/s in the patient group and 6.0 ± 1.0 m/s in the control group (p < 0.001). The same measurements were repeated during a control visit at the end of 1 month. Following treatment, a significant decrease was observed in PWV in all patient groups compared to baseline (p < 0.001). Subgroup analysis showed significantly decreased PWV in all drug groups, with the most prominent decrease in the topiramate group.

CONCLUSIONS

The increased PWV demonstrated in migraine patients in this study stands out as an additional parameter elucidating endothelial dysfunction in these patients. Decreasing the number of migraine attacks with prophylactic treatment may reduce PWV and decrease cardiovascular risk in long-term follow-up.

[Importance of perimetric differential diagnostics in patients with primary open-angle glaucoma]

Functional deficits in glaucomatous optic neuropathy are, apart from other disturbances in the visual field, typically detected with achromatic perimetry as a well accepted gold standard. With the development of new perimetric devices and strategies (e.g. short wave perimetry, frequency doubling perimetry and flicker perimetry) individually different patterns of scotomas in the different perimetric devices could be recognized. The reasons for this could be a different sensitivity reaction of the ganglion cell subpopulations to an increased intraocular pressure as well as an influence of the underlying systemic diseases. To obtain a differentiated detection of the functional loss in the visual field in glaucoma, the use of different perimetric methods seems to be reasonable and helpful.

Ventricular tachycardia during basilar-type migraine attack

Autonomic dysfunction is a characteristic of migraine attacks, rarely, even cardiac repolarization abnormalities have been associated with migraine. We report a case of documented ventricular tachycardia during basilar-type migraine attack. The therapeutic implications of such a co-occurrence as well as a possible relationship between ventricular tachycardia and the underlying biology of basilar-type migraine are discussed.

Contraceptive hormone use and cardiovascular disease

Contraceptive hormones, most commonly prescribed as oral contraceptives (OCs), are a widely utilized method to prevent ovulation, implantation, and, therefore, pregnancy. The Women's Health Initiative demonstrated cardiovascular risk linked to menopausal hormone therapy among women without pre-existing cardiovascular disease, prompting a review of the safety, efficacy, and side effects of other forms of hormone therapy. A variety of basic science, animal, and human data suggests that contraceptive hormones have antiatheromatous effects; however, relatively less is known regarding the impact on atherosclerosis, thrombosis, vasomotion, and arrhythmogenesis. Newer generation OC formulations in use indicate no increased myocardial infarction risk for current users, but a persistent increased risk of venous thromboembolism. There are no cardiovascular data available for the newest generation contraceptive hormone formulations, including those that contain newer progestins that lower blood pressure, as well as the nonoral routes (transdermal and vaginal). Current guidelines indicate that, as with all medication, contraceptive hormones should be selected and initiated by weighing risks and benefits for the individual patient. Women 35 years and older should be assessed for cardiovascular risk factors including hypertension, smoking, diabetes, nephropathy, and other vascular diseases, including migraines, prior to use. Existing data are mixed with regard to possible protection from OCs for atherosclerosis and cardiovascular events; longer-term cardiovascular follow-up of menopausal women with regard to prior OC use, including subgroup information regarding adequacy of ovulatory cycling, the presence of hyperandrogenic conditions, and the presence of prothrombotic genetic disorders is needed to address this important issue.

Migraine-associated risks and comorbidity

This review reports important co-morbid conditions of migraine and resulting consequences for the choice of acute and preventive treatments of migraine. Comorbidity in this context means the occurrence of two diseases in an individual beyond chance. The basis of comorbidity can be genetic and/or based on common environmental factors. In some cases, the temporal relationship is unclear and one disease can cause another disease. In order to prove a real comorbidity, large-scale and well-performed epidemiological studies are required.

Comorbid neuropathologies in migraine: an update on cerebrovascular and cardiovascular aspects

Several conditions are comorbid with migraine; our review is focused on the relation between migraine, and cerebrovascular and cardiovascular diseases. Despite many studies showed an association between migraine and patent foramen ovale, it is still not known whether its presence might be causal for the migraine pathogenesis and currently its closure cannot be recommended for migraine prevention. On the contrary, conflicting epidemiological data link migraine to arterial hypertension and the use of antihypertensive agents acting on the renin-angiotensin system sounds promising in migraine prevention. A complex bidirectional relation exists between migraine and stroke, and new evidences show a clear association between migraine and coronary heart disease. In both conditions, migraine represents a defined risk factor although the magnitude of the risk varies across the different studies. However, since the risk is low in the general population, it is not possible to identify which migraineurs will develop a cardiovascular or a cerebrovascular event making difficult to apply preventive measures.

Comparison of CGRP and NO responses in the human peripheral microcirculation of migraine and control subjects

Calcitonin gene-related peptide (CGRP) and nitric oxide (NO) are two molecules shown to have a role in migraine pathophysiology. Our objective was to test the hypothesis that migraine subjects are particularly sensitive to these signal molecules. The cutaneous microvascular responses to endothelial and non-endothelial dependent dilators were tested using laser Doppler flowmetry in combination with iontophoresis. The blood flow responses to iontophoretic administration of the endothelium-dependent vasodilator acetylcholine (ACh), or to the endothelium-independent dilators sodium nitroprusside (SNP) and CGRP, and to local warming (44 degrees C) were compared in this controlled trial. The design was that of two arms: patients diagnosed with migraine without aura (n = 9) for >10 years were compared with nine healthy subjects matched for age and gender (seven female and two male, age range 30-60 years). Iontophoretic administration resulted in local vasodilation. ACh induced a relaxation of 1225 +/- 245% (relative to baseline) in controls and 1468 +/- 368% (P > 0.05) in migraine. The responses to SNP were 873 +/- 193% in controls and 1080 +/- 102% (P > 0.05) in migraine subjects. The responses to CGRP were 565 +/- 89% in controls and 746 +/- 675% (P > 0.05) in migraine patients. The responses to local heating which induced maximum dilation did not differ between the groups (1976 +/- 314% for controls and 1432 +/- 226% in migraine; P > 0.05. We conclude that there is no change in the microvascular responsiveness of the subcutaneous microvasculature in migraine.

Migraine and ischaemic vascular events

An association between migraine and ischaemic vascular events, particularly ischaemic stroke, has been debated for many years. The pathophysiology of migraine has been explored in detail, and it is known that a dysfunction of brain cells and arteries is a major component of this disorder. The involvement of cerebral arteries during the migraine attack as well as the high prevalence of migraine among young individuals with ischaemic stroke has led to the hypothesis that migraine may be a risk factor for ischaemic stroke. Furthermore, there is evidence that the vascular nature of migraine is not limited to meningeal blood vessels and that migraine and overall cardiovascular disease may share aetiological pathways. The aim of this review is to summarize the epidemiological evidence that links migraine with ischaemic stroke and ischaemic heart disease and to discuss potential biological mechanisms.

Patent foramen ovale, stroke, and cardiovascular disease in migraine

PURPOSE OF REVIEW

We will review the literature on the association between migraine with patent foramen ovale, stroke, and coronary heart disease.

RECENT FINDINGS

The prevalence of patent foramen ovale in patients with migraine with aura is significantly higher than in nonmigraine controls and migraineurs without aura. However, there is currently no evidence to support a causal relationship. Migraine with aura has been consistently associated with increased risk of ischemic stroke in several epidemiologic studies. Migraine with aura is associated with a more unfavourable cardiovascular risk profile and recent data suggest that the association between migraine with aura and stroke may extend to overall cardiovascular disease. Identification of migraine patients at particular risk for stroke or other vascular events is impossible based on current knowledge.

SUMMARY

Migraine with aura and patent foramen ovale have higher coincidences than expected by chance only. It is possible that both conditions are inherited together. Until now there has been no evidence from placebo-controlled randomized trials that closure of patent foramen ovale improves migraine with aura. There is increasing evidence that migraine with aura is not only a risk factor for ischemic stroke but also for myocardial infarction and other ischemic vascular events.

Stroke and chest pain in young people with migraine

BACKGROUND

Cerebrovascular and cardiovascular complications in migraineurs may be part of the migraine process and also consequent to triptan treatment.

AIM

To determine the frequency, subtypes and associations of migraine-associated stroke and angina in young people (18-49 years).

METHODS

Patients were derived from a tertiary referral migraine and stroke registry. Migraine-associated stroke was classified according to the four groups described by Welch and by the TOAST etiological stroke classification. A clinical description of angina during a migraine attack was required for the diagnosis of cardiac migraine without concomitant triptan or other vasoactive medications.

RESULTS

Of the young patients with stroke (349/1316; 26.5%), there were 30 (30/349; 8.6%) who had migraine at the time of stroke when categorized by the Welch classification type II to IV (type II n = 5, type III n = 2, type IV n = 3). Comparison of type I (n = 20) versus types II-IV (n = 10) showed significant difference (P = .03). Topographically the lesions were distributed into the partial anterior circulation (n = 8) and posterior circulation (n = 2) (P = .04). Comparison of anterior and posterior circulation territories of infarction indicated significant difference (n = 26/30 and 4/30; P = .01). The stroke etiological subtypes included cardiogenic (n = 5), atherogenic (n = 15), other (n = 5), and unknown (n = 5), with none diagnosed with small-vessel cerebrovascular disease. Traditional stroke mechanistic entities (cardiac and atherogenic) differed significantly in comparison to the other and unknown categories P = .05. Cardiovascular patients with angina during a migraine attack (n = 9/1040; 0.9%), included IHS subtypes; migraine without aura (n = 4), migraine with aura (n = 4), and complicated migraine (n = 1). One patient required cardiac catheterization on account of significant ECG changes, with documented, reversible vasospasm.

CONCLUSION

(i) Migraine-induced stroke remains controversial, with only two probable cases of type Welch III A+B in a large registry. (ii) Cardiac migraine may be a distinct entity requiring careful differentiation from triptan-induced chest pain.

Migraines, angiographic coronary artery disease and cardiovascular outcomes in women

PURPOSE

There are conflicting data regarding the association between migraines and cardiovascular events. We evaluated the relationship between migraine headaches, angiographic coronary artery disease, and cardiovascular events in women.

SUBJECTS AND METHODS

The Women's Ischemia Syndrome Evaluation (WISE) study is a National Heart, Lung and Blood Institute (NHLBI)-sponsored prospective, multicenter study aiming to improve ischemia evaluation in women. A total of 944 women presenting with chest pain or symptoms suggestive of myocardial ischemia were enrolled and underwent complete demographic, medical, and psychosocial history, physical examination, and coronary angiography testing. A smaller subset of 905 women, representing a mean age of 58 years, answered questions regarding a history of migraines. We prospectively followed 873 women for 4.4 years for cardiovascular events and all-cause mortality.

RESULTS

Women reporting a history of migraines (n=220) had lower angiographic coronary severity scores, and less severe (> or = 70% luminal stenosis) angiographic coronary artery disease compared to women without a history of migraines (n=685). These differences remained statistically significant after adjustment for age and other important cardiac risk factors. On prospective follow-up of a median of 4.4 years, women with a history of migraines were not more likely to have a cardiovascular event (hazard ratio [HR] 1.2; 95% confidence interval [CI], 0.93-1.58) and migraines did not predict all-cause mortality (HR 0.96; 95% CI, 0.49-1.99).

CONCLUSION

Among women undergoing coronary angiography for suspected ischemia, those reporting migraines had less severe angiographic coronary artery disease. We could not support an association between migraines and cardiovascular events or death. Further research studying the common pathophysiology underlying migraines and cardiovascular disease is warranted.

Migraine and Patent Foramen Ovale: A Residual Coincidence or a Pathophysiological Intrigue?

Migraine is one of the most common neurological disorders and one of the most frequent primary headaches. It imposes a significant burden on the affected individuals, society and health care system. As the etiology and pathophysiology of migraine are not well understood, treatment is largely symptomatic. Patent foramen ovale is a remnant of a fetal circulation and is highly prevalent in the general population. Its presence was linked to several disorders including migraine. The aim of this review was to search in the available data the answer to the question whether the link between migraine and patent foramen ovale is coincidental or whether they represent a pathophysiological entity.

Forearm vascular response to nitric oxide and calcitonin gene-related peptide: comparison between migraine patients and control subjects

The forearm vascular response to nitric oxide (NO) and calcitonin gene-related peptide (CGRP) was investigated in 10 migraine patients and 10 matched control subjects. Changes in forearm blood flow (FBF) during intrabrachial infusion of: (i) serotonin (releasing endogenous NO), (ii) sodium nitroprusside (SNP, exogenous NO-donor), and (iii) CGRP were measured using venous occlusion plethysmography. Flow-mediated dilation (FMD) of the brachial artery, a measure for the endogenous release of NO reactive to occlusion, was measured using ultrasound and expressed as percentage change vs. baseline diameter. FBF ratio (i.e. FBF in the infused over the control arm) at baseline (1.1 +/- 0.1) did not differ between both populations. Serotonin, SNP and CGRP induced a dose-dependent increase (P < 0.001) in FBF ratio in controls (to 2.8 +/- 0.3, 6.7 +/- 1.4 and 6.9 +/- 1.2 at the highest dose, respectively) and migraineurs (2.5 +/- 0.4, 5.6 +/- 0.8 and 6.5 +/- 1.3, respectively); these ratios did not differ between both groups. FMD was comparable in control subjects (5.8 +/- 1%) and migraine patients (5.2 +/- 1%). Based on the forearm vascular response to NO and CGRP, migraine patients do not display generalized changes in vascular function.

Migraine and other headaches: associations with Rose angina and coronary heart disease

OBJECTIVE

To examine the association between a lifetime history of migraines and other headaches with and without aura and Rose angina and coronary heart disease (CHD).

METHODS

Participants were 12,409 African American and white men and women from the Atherosclerosis Risk in Communities Study, categorized by their lifetime history of headaches lasting > or =4 hours (migraine with aura, migraine without aura, other headaches with aura, other headaches without aura, no headaches). Gender-specific associations of headaches with Rose angina and CHD, adjusted for sociodemographic and cardiovascular disease risk factors, were evaluated using Poisson regression.

RESULTS

Participants with a history of migraines and other headaches were more likely to have a history of Rose angina than those without headaches. The associations were stronger for migraine and other headaches with aura (prevalence ratio [PR] = 3.0, 95% CI = 2.4, 3.7 and PR = 2.0, 95% CI = 1.5, 2.7 for women; PR = 2.2, 95% CI = 1.2, 3.9 and PR = 2.4, 95% CI = 1.4, 3.9 for men) than for migraine and other headaches without aura (PR = 1.5, 95% CI = 1.2, 1.9 and PR = 1.3, 95% CI = 1.1, 1.6 for women; PR = 1.9, 95% CI = 1.2, 2.9 and OR = 1.4, 95% CI = 1.0, 1.8 for men). In contrast, migraine and other headaches were not associated with CHD, regardless of the presence of aura.

CONCLUSIONS

The lack of association of migraines with coronary heart disease suggests that the association of migraine with Rose angina is not related to coronary artery disease. Future research assessing other common underlying pathologic mechanisms is warranted.

Are migraine and coronary heart disease associated? An epidemiologic review

In evaluating the cardiovascular risks of triptans (5-HT(1B/1D) agonists) for the treatment of migraine, the possible relationship between migraine and cardiovascular disease warrants careful assessment. The vascular nature of migraine is compatible with the possibility that migraine is a manifestation of cardiovascular disease or is linked to cardiovascular disease via a common mechanism. If so, then migraine itself--independent of the use of triptans--may be associated with an increased risk of cardiac events. This article considers the epidemiologic literature pertinent to evaluating the association of migraine with coronary heart disease. The research reviewed herein fails to support an association between migraine and coronary heart disease. First, data from several large cohort studies show that the presence of migraine does not increase risk of coronary heart disease. Furthermore, although migraineurs are generally more likely than nonmigraineurs to report chest pain, the presence of chest pain in most studies did not predict serious cardiac events such as myocardial infarction. That the gender- and age-specific prevalence of migraine does not overlap with that of coronary heart disease is also consistent with a lack of association between migraine and atherosclerotic cardiovascular disease. While migraine appears not to be associated with coronary heart disease, preliminary evidence suggests a possible link of migraine with vasospastic disorders such as variant angina and Raynaud's phenomenon. These results warrant further investigation in large prospective studies.

Cardiovascular tolerability and safety of triptans: a review of clinical data

Triptans are not widely used in clinical practice despite their well-established efficacy, endorsement by the US Headache Consortium, and the demonstrable need to employ effective intervention to reduce migraine-associated disability. Although the relatively restricted use of triptans may be attributed to several factors, research suggests that prescribers' concerns about cardiovascular safety prominently figure in limiting their use. This article reviews clinical data--including results of clinical trials, postmarketing studies and surveillance, and pharmacodynamic studies--relevant to assessing the cardiovascular safety profile of the triptans. These data demonstrate that triptans are generally well tolerated. Chest symptoms occurring during use of triptans are usually nonserious and usually not attributed to ischemia. Incidence of triptan-associated serious cardiovascular adverse events in both clinical trials and clinical practice appears to be extremely low. When they do occur, serious cardiovascular events have most often been reported in patients at significant cardiovascular risk or in those with overt cardiovascular disease. Adverse cardiovascular events also have occurred, however, in patients without evidence of cardiovascular disease. Several lines of evidence suggest that nonischemic mechanisms are responsible for sumatriptan-associated chest symptoms, although the mechanism of chest symptoms has not been determined to date. Importantly, most of the clinical trials and clinical practice data on triptans are derived from patients without known cardiovascular disease. Therefore, the conclusions of this review cannot be extended to patients with cardiovascular disease. The cardiovascular safety profile of triptans favors their use in the absence of contraindications.

Consensus Statement: Cardiovascular Safety Profile of Triptans (5-HT1B/1D Agonists) in the Acute Treatment of Migraine

BACKGROUND

Health care providers frequently cite concerns about cardiovascular safety of the triptans as a barrier to their use. In 2002, the American Headache Society convened the Triptan Cardiovascular Safety Expert Panel to evaluate the evidence on triptan-associated cardiovascular risk and to formulate consensus recommendations for making informed decisions for their use in patients with migraine.

OBJECTIVE

To summarize the evidence reviewed by the Triptan Cardiovascular Safety Expert Panel and their recommendations for the use of triptans in clinical practice.

PARTICIPANTS

The Triptan Cardiovascular Safety Expert Panel was composed of a multidisciplinary group of experts in neurology, primary care, cardiology, pharmacology, women's health, and epidemiology.

EVIDENCE AND CONSENSUS PROCESS

An exhaustive search of the relevant published literature was reviewed by each panel member in preparation for an open roundtable meeting. Pertinent issues (eg, cardiovascular pharmacology of triptans, epidemiology of cardiovascular disease, cardiovascular risk assessment, migraine) were presented as a prelude to group discussion and formulation of consensus conclusions and recommendations. Follow-up meetings were held by telephone.

CONCLUSIONS

(1) Most of the data on triptans are derived from patients without known coronary artery disease. (2) Chest symptoms occurring during use of triptans are generally nonserious and are not explained by ischemia. (3) The incidence of serious cardiovascular events with triptans in both clinical trials and clinical practice appears to be extremely low. (4) The cardiovascular risk-benefit profile of triptans favors their use in the absence of contraindications.

Electrocardiographic changes during migraine attacks

OBJECTIVES

To clarify whether electrocardiographic (ECG) changes can be identified during a migraine attack and to determine whether there are ECG differences between periods with and without headache.

BACKGROUND

The clinical signs and symptoms of migraine point to involvement of the autonomic nervous system, and especially to disrupted regulation of the circulatory system and autonomic balance. This disruption may be more marked during a migraine attack. During a migraine attack, autonomic imbalance within the heart and its vessels conceivably may result in ECG abnormalities.

METHODS

In 30 patients with migraine, the ECG variables of heart rate, abnormalities of rhythm, PR interval, QRS duration, corrected QT interval, T inversion, and ST-segment changes were recorded during migraine attacks and pain-free periods.

RESULTS

Of the 30 patients studied during a migraine attack, 9 (30%) had one or more abnormalities of rhythm (including sinus arrhythmia, atrial premature contraction, and ventricular premature contraction), 20% had PR intervals greater than 0.20 seconds, 40% had corrected QT intervals greater than 0.44 seconds, 66% had T inversion, and 40% had ST-segment abnormalities. No patient had arrhythmia, PR intervals greater than 0.20 seconds, or corrected QT intervals greater than 0.44 seconds during a pain-free period. No differences were noted for ST-segment changes, T inversion, and total ECG changes between periods with and without headache, but both PR and corrected QT intervals were significantly longer during migraine attacks than during pain-free periods.

CONCLUSIONS

We conclude that ECG abnormalities often are present during a migraine attack, and for most of these, particularly PR and corrected QT interval lengthening, these abnormalities will be absent or less prominent during pain-free intervals.

Cranial and peripheral interictal vascular changes in migraine patients

As migraine is associated with an increased risk for ischaemic stroke and peripheral vasospastic disorders, it was hypothesized that interictal vascular changes may be present in migraine patients. Using ultrasound and applanation tonometry, the cardiovascular properties of migraine patients were compared with those of matched control subjects. Vascular parameters of the carotid arteries, cardiac output and systemic vascular resistance did not differ between both groups. Right temporal artery diameter was larger in migraine patients (mean difference 101 micro m; 95% confidence interval (CI) 9/194 micro m; P = 0.033). At the brachial artery, migraine patients displayed a smaller distension (difference -24 micro m; 95% CI -45/-4 micro m; P = 0.021) and a decreased compliance (difference -0.025 mm2/kPa; 95% CI -0.047/-0.003 mm2/kPa; P = 0.024). Thus, migraine patients display an increased peripheral arterial stiffness. The presence of these interictal vascular changes suggests that migraine might be part of a more generalized vascular disorder.

Migraine and coronary heart disease in women and men

OBJECTIVE

We evaluated migraine as an independent risk factor for subsequent coronary heart disease (CHD) events among women in the Women's Health Study (WHS) and men in the Physicians' Health Study (PHS).

BACKGROUND

Although several studies have suggested that migraine is associated with increased risk of stroke, there are few and conflicting data on whether migraine predicts risk of future CHD events.

METHODS

The WHS is an ongoing randomized, double-blind, placebo-controlled trial of low-dose aspirin and vitamin E in the primary prevention of cardiovascular disease and cancer in 39876 women health professionals aged > or =45 years in 1993, and the PHS is a completed randomized, double-blind, placebo-controlled trial of aspirin and beta-carotene in the primary prevention of cardiovascular disease and cancer in 22071 men physicians aged 40 to 84 years in 1982. Primary endpoints were defined as major CHD (nonfatal myocardial infarction [MI] or fatal CHD) and total CHD (major CHD plus angina and coronary revascularization).

RESULTS

After adjusting for other CHD risk factors, female health professionals and male physicians reporting migraine were not at increased risk for subsequent major CHD (women: relative risk [RR], 0.83; 95% confidence interval [CI], 0.53 to 1.29; men: RR, 1.02; 95% Cl, 0.79 to 1.31) or total CHD (women: RR, 1.01; 95% Cl, 0.76 to 1.34; men: RR, 0.98; 95% Cl, 0.82 to 1.18). When considered separately, there was also no increase in risk of MI or angina.

CONCLUSION

These prospective data suggest that migraine is not associated with increased risk of subsequent CHD events in women or men.

Cervical carotid artery vasospasms causing cerebral ischemia: detection by immediate vascular ultrasonographic investigation

BACKGROUND

The etiology of cerebral ischemic accidents in young adults often remains unclarified.

CASE DESCRIPTION

A 32-year-old woman presented after multiple episodes of left monocular visual impairment and right-sided focal signs. MRI revealed a low-flow infarction on the left; color-coded duplex sonography (CCDS), however, showed normal vascular findings. During the inpatient rehabilitation, a renewed visual impairment occurred; an immediate CCDS examination now demonstrated a filiform stenosis of the left internal carotid artery (ICA) 4 cm above the origin and indirect signs of a severe stenosis of the right ICA. Results of a follow-up examination 18 hours later were again normal. Six weeks later, on reoccurrence of visual impairment, a reversible stenosis of the left ICA was again demonstrated. A search for possible causes of vasospasm was unsuccessful. After treatment with calcium antagonists the patient was free of complaints (with the exception of 3 very short attacks of visual impairment) during the following 12 months.

CONCLUSIONS

Cervical carotid artery vasospasms can apparently occur spontaneously without a mechanical trigger. Because their detection is difficult, vasospasms may go undetected.