Common Misconceptions in Migraine Management: Triptans contraindications.

Migraine aura, serotonin and the vascular theory

Triptans, a cornerstone in migraine rescue therapy since their introduction in 1991, have dramatically improved the lives of those suffering from migraines. They operate by enhancing the role of serotonin in the brain. However, serotonin has many functions in the brain and other organs; and one of these functions is constricting the small arteries. This is the same mechanism that our platelets utilize to reduce blood flow in an open wound so they get the chance to clump and form a clot.

Historically, this association between migraine, serotonin, and vascular constriction paved the way to a popular conjecture of the origin of migraine called the vascular theory. According to this theory, migraine headaches begin because of excessive serotonin release (dumped by the platelets circulating in the brain) causing narrowing of the arteries. When serotonin is exhausted, the arteries dilate and then they start causing pain as the blood rushes through these “primed” dilated arteries. This theory explained why some people get auras, which are stroke like symptoms (visual changes, tingling and numbness, weakness, difficulty with speech…etc) before they have their migraine headaches, and it was also thought to explain why some patients feel their heart beats, or see the dilated veins in their temples while having an attack.

Years later, the vascular theory was refuted, and considered a “cute” attempt in understanding migraine; a neurologic disease that is much more complex than previously thought. The theory was relinquished after it became clear that migraine pain is not related to the dilated arteries, and that the effect of triptans on managing migraine pain has no relation to its effects on the blood vessel, which is mild in any case.

Debunking the Myth: The Safety of Triptans

One sequela of the vascular theory that persisted even as the theory became obsolete was the notion that triptans were contraindicated in patients with certain types of auras. As explained above, auras were understood to be stroke-like events, and since the triptans theoretically would worsen the vessel constrictions, it was believed it may increase the chances of causing strokes in patients with aura. This has been especially applied when the aura is not only consistent of visual changes, but any of a complex constellation of symptoms such as tingling, vertigo and/or weakness (collectively called brainstem auras)
The thing is this was never found to be the case.
However, no high-quality studies have demonstrated an increased stroke risk from triptan use in patients with aura, including those experiencing brainstem aura symptoms. On the contrary, extensive research (cited below) confirms that triptans are safe for migraine patients with aura symptoms, debunking the baseless restriction and broadening treatment possibilities. This is especially important as certain symptoms such as vertigo (dizziness) or tingling are very common in migraine headaches.

The Impact of Re-evaluating Triptan Use

Many migraine sufferers have been unjustly advised against the use of triptans based on outdated interpretations of their contraindications. This has not only limited their treatment options but also prolonged their suffering. In my practice, allowing patients to use triptans, previously denied to them, has significantly improved their quality of life. It’s crucial to question outdated practices and, with informed discussion with healthcare providers, consider triptans as a viable treatment option for migraines, even those with aura symptoms.

A Note of Caution

While this information aims to educate and promote informed discussions, it is not a substitute for professional medical advice tailored to your individual circumstances.