QT Prolongation, Torsade de Pointes, Myocardial Ischemia From Coronary Vasospasm, and Headache Medications. Part 1: Review of Serotonergic Cardiac Adverse Events With a Triptan Case

Migraine and heart: A reality check

Migraine is a common neurological disorder affecting 12% of the global population. The common risk factors are adolescent age, genetics, and female sex, and are triggered by hormonal fluctuations, emotional stress, sensory overload, weather changes, alcohol consumption, fasting, cheese, chocolate, smoked fish, yeast extract, cured meats, artificial sweeteners, food preservatives containing nitrates and nitrites, and sleep disturbances. Migraine with aura is associated with an increased risk of cardiovascular disease events, such as myocardial infarction, angina pectoris, and cardiac arrhythmias, and has recently been added to the QRISK3 cardiovascular disease prediction score. Population-based cohort studies have shown a significant association of migraine with aura and cardiac arrhythmias, most importantly atrial fibrillation. Patients suffering from migraine with aura are at an increased risk for cardiac arrhythmias; thus, it is essential to screen these patients for undiagnosed cardiovascular disorders.

Progress in Traditional Chinese Medicine for the Treatment of Migraine

Migraine is a recurrent disease with complex pathogenesis and is difficult to cure. At present, commercially available western migraine drugs are prone to generate side effects while treating the disease. Traditional Chinese medicine (TCM) avoids side effects via treatment with the principles of “treating both symptoms and root causes”, “overall adjustment”, and “treatment based on syndrome differentiation”. Three strategies of drug treatment were developed based on the syndromes, i.e., removing stasis, calming liver Yang, and reinforcing deficiency. Prescriptions of removing stasis mostly contain Chuanxiong rhizome (Chuan Xiong) to remove blood stasis by promoting blood circulation and improve properties of hemorheology, and Da Chuan Xiong Formula (DCXF) is a traditional prescription widely used in clinical practice. Prescriptions of calming liver Yang usually take Ramulus Uncariae cum Uncis (Gou Teng) as the main herb, which can calm the liver Yang via improving vasomotor function, and Tian Ma Gou Teng Decoction (TMGTD) is the representative drug. For reinforcing deficiency, Chinese doctors frequently utilize Angelica Sinensis (Dang Gui) and Astragali Radix (Huang Qi) to nourish blood and Qi in order to improve the weak state of human body; Dang Gui Bu Xue Decoction (DGBXD) is the commonly used prescription. These strategies not only treat the symptoms of diseases but also their root causes, and with the features of multiple targets, in multiple ways. Therefore, TCM prescriptions have obvious advantages in the treatment of chronic diseases such as migraine. In this review, we provided an overview of the pathogenesis of migraine and the function of representative TCM preparations in therapy of migraine as well as the mechanism of action according to effective researches, in order to provide reference and clue for further researches.

Triptan and ergotamine overdoses in the United States

Objective

To examine the clinical outcomes of intentional overdoses involving triptans and ergotamines with a retrospective review of the National Poison Data System (NPDS).

Methods

This was a 5-year retrospective cross-sectional study (2014–2018) using the NPDS. Demographics, exposure characteristics, and outcomes were described. Univariate logistic regression was used to estimate the odds ratio (OR) for major effect or death. A multivariable logistic regression model with inclusion criteria ofp< 0.1 in univariate analysis was implemented with backwards selection.

Results

In this population (n = 1,489), multiple exposure was most common (n = 1,145). The mean age was 31.2 years and 1,197 (80.4%) participants were female. Major effects from a single exposure were seen in <1% with no recorded deaths. Triptan ingestion (n = 328) resulted in hypertension (14%), tachycardia (10.7%), drowsiness (11%), nausea (6.4%), vomiting (4.6%), vertigo (4%), chest pain (3.7%), and diaphoresis (2.4%). Ergotamine ingestion (n = 16) resulted in abdominal pain (16%), vomiting (12.5%), numbness (12.5%), nausea (6.3%), diarrhea (6.3%), and vertigo (6.3%). No clinical effect was seen in 90 (26.2%). No cases met Hunter criteria for serotonin syndrome. There is risk of major event or death due to age (OR 1.02; 95% confidence interval [CI] 1.01–1.04;p= 0.004), multiple product exposure (OR 9.50; 95% CI 2.29–39.48;p= 0.002), and concomitant overdose with benzodiazepines (OR 1.71; 95% CI 1.05–2.78;p= 0.032) or tricyclic antidepressants (OR 3.16; 95% CI 1.88–5.31;p< 0.001).

Conclusion

The risk of major effect or death was low and predicted by age, multiple product exposure, and concomitant benzodiazepine or tricyclic antidepressant. The triptan toxidrome consists of hypertension, tachycardia, and drowsiness. The toxic effects of ergotamine are acute gastrointestinal syndrome with vertigo and numbness. No cases of serotonin syndrome were seen.

Electrographic indices in migraine patients: A systematic review and meta-analysis

BACKGROUND AND AIM

Migraine patients can exhibit autonomic dysregulation, in turn leading to cardiac conduction and repolarization abnormalities. This systematic review and meta-analysis evaluated the electrocardiographic changes in migraineurs.

METHOD

PubMed and Embase databases were searched for human studies using the search terms 'migraine' and 'electrocardiogram' until 15th December 2018, identifying 108 and 131 studies.

RESULTS

Thirteen studies involving 667 migraineurs and 208 normal subjects included (mean age=30.7, total male percentage=19.8%) were included. A longer mean QTc interval (standard mean difference=7.89, 95% confidence interval=[3.29, 12.49], p=0.0008) and higher frequency of QTc prolongation (risk ratio [RR]=6.23, [2.86-13.58], p<0.00001), but no difference in PR-interval (SMD=4.33, [-3.90-12.56], p=0.30) were observed during migraine attacks compared to pain-free periods. P-wave dispersion was higher in migraine patients compared to controls (mean difference=3.62, [1.03-6.21], p=0.006). RR-interval were statistically indistinguishable between migraine patients and controls (SMD=0.08, [-0.65-0.81], p=0.83), or between migraineurs with and without aura (SMD=-0.03, [-0.44-0.38], p=0.89). Deep breathing ratio was significantly lower in migraineurs compared to controls (SMD=-0.27, 95% CI=[-0.46, -0.08], p=0.006) but similar between migraineurs with and without aura (SMD=-0.04, [-0.27-0.19], p=0.74). No significant difference in Valsalva ratio is found between migraineurs and controls (SMD=0.10, [-0.32-0.53], p=0.63) or between migraineurs with and without aura (SMD=-0.17, [-0.40-0.06], p=0.14). Root mean square of successive differences (RMSSD) (SMD=-0.07, [-1.10-0.95], p=0.89) and standard deviation of NN intervals (SDNN) (SMD=-0.10, [-0.61-0.41], p=0.71) did not significantly differ between migraine patients and controls.

CONCLUSION

Electrocardiographic alterations are observed in migraine patients compared to controls, especially during migraine attacks.

Study on the absorbed fingerprint-efficacy of yuanhu zhitong tablet based on chemical analysis, vasorelaxation evaluation and data mining

Yuanhu Zhitong Tablet (YZT) is an example of a typical and relatively simple clinical herb formula that is widely used in clinics. It is generally believed that YZT play a therapeutical effect in vivo by the synergism of multiple constituents. Thus, it is necessary to build the relationship between the absorbed fingerprints and bioactivity so as to ensure the quality, safety and efficacy. In this study, a new combinative method, an intestinal absorption test coupled with a vasorelaxation bioactivity experiment in vitro, was a simple, sensitive, and feasible technique to study on the absorbed fingerprint-efficacy of YZT based on chemical analysis, vasorelaxation evaluation and data mining. As part of this method, an everted intestinal sac method was performed to determine the intestinal absorption of YZT solutions. YZT were dissolved in solution (n = 12), and the portion of the solution that was absorbed into intestinal sacs was analyzed using rapid-resolution liquid chromatography coupled with quadruple time-of-flight mass spectrometry (RRLC-Q-TOF/MS). Semi-quantitative analysis indicated the presence of 34 compounds. The effect of the intestinally absorbed solution on vasorelaxation of rat aortic rings with endothelium attached was then evaluated in vitro. The results showed that samples grouped by HCA from chemical profiles have similar bioactivity while samples in different groups displayed very different. Moreover, it established a relationship between the absorbed fingerprints and their bioactivity to identify important components by grey relational analysis, which could predict bioactive values based on chemical profiles and provide an evidence for the quantification of multi-constituents.