title: Migraine can be induced by sildenafil without changes in middle cerebral artery diameter.
abstract: Migraine is considered a neurovascular disease involving dilatation of cerebral arteries. Nitric oxide (NO) donors induce dilatation of cerebral and extracranial arteries and migraine, but NO has several mechanisms of action in addition to its cyclic guanosine monophosphate (cGMP)-mediated vasodilatation. We examined whether sildenafil (Viagra), a selective inhibitor of cGMP-hydrolysing phosphodiesterase 5 (PDE5), which acts exclusively by increasing cGMP, can induce migraine and dilatation of cerebral arteries. We included 12 patients with migraine without aura in this double-blind, placebo-controlled crossover study, in which placebo or sildenafil 100 mg was administered orally on two separate days. Blood flow velocity in the middle cerebral artery (V(mca)) was recorded by transcranial Doppler ultrasonography and regional cerebral blood flow in the territory of the middle cerebral artery (rCBF(mca)) was measured using SPECT (single photon emission computed tomography) and xenon 133 inhalation. Radial and temporal artery diameters were studied using high-frequency ultrasonography. Headache response, tenderness of pericranial muscles, blood pressure and heart rate were measured repeatedly. We found that migraine attack was induced by sildenafil in 10 of 12 migraine patients and by placebo in two of 12 patients (P = 0.01). V(mca) (P = 0.1) and rCBF(mca) (P = 0.93) remained unchanged after sildenafil. Temporal (P = 0.47) and radial (P = 0.87) artery diameter and pericranial tenderness (P = 0.16) were unaffected by sildenafil. Systolic and diastolic blood pressures were unchanged but heart rate increased from a mean of 62 +/- 2 to 74 +/- 3 beats/min (P = 0.01) after sildenafil. Our results demonstrate that migraine may be induced via a cGMP-dependent mechanism, and we show for the first time that this occurs without initial dilatation of the middle cerebral artery. We propose that triggering mechanisms may reside within the perivascular sensory nerve terminals or the brainstem. However, other sites of action may also be possible and future studies are needed to elucidate this. In the clinical use of sildenafil, patients who have migraine should be informed about the risk of migraine attacks.
authors.affiliation: Department of Neurology, Glostrup Hospital, University of Copenhagen, Glostrup, Copenhagen, Denmark. ckruuse@dadlnet.dk
authors.forename: Christina
authors.initials: C
authors.lastname: Kruuse
authors.forename: Lars Lykke
authors.initials: LL
authors.lastname: Thomsen
authors.forename: Steffen
authors.initials: S
authors.lastname: Birk
authors.forename: Jes
authors.initials: J
authors.lastname: Olesen
mesh_terms: D015106:3',5'-Cyclic-GMP Phosphodiesterases; D000328:Adult; D001783:Blood Flow Velocity / Q000187:drug effects; D018592:Cross-Over Studies; D054706:Cyclic Nucleotide Phosphodiesterases, Type 5; D004311:Double-Blind Method; D005260:Female; D006261:Headache / Q000139:chemically induced; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D008297:Male; D020768:Middle Cerebral Artery / Q000000981:diagnostic imaging*; D008881:Migraine Disorders / Q000139:chemically induced* / Q000000981:diagnostic imaging; D010726:Phosphodiesterase Inhibitors; D010727:Phosphoric Diester Hydrolases; D010879:Piperazines; D011687:Purines; D017534:Radial Artery / Q000000981:diagnostic imaging; D000068677:Sildenafil Citrate; D013450:Sulfones; D013699:Temporal Arteries / Q000000981:diagnostic imaging; D015899:Tomography, Emission-Computed, Single-Photon; D018608:Ultrasonography, Doppler
chemical_list: D010726:Phosphodiesterase Inhibitors; D010879:Piperazines; D011687:Purines; D013450:Sulfones; D000068677:Sildenafil Citrate; D010727:Phosphoric Diester Hydrolases; D015106:3',5'-Cyclic-GMP Phosphodiesterases; D054706:Cyclic Nucleotide Phosphodiesterases, Type 5; C517381:PDE5A protein, human