When to stress over triptans: a Markov analysis of cardiovascular risk in migraine treatment.
BACKGROUND
Migraines affect 10% of the U.S. population and the episodes are frequently associated with significant disability. Triptans, 5HT1 receptor agonists, can be highly effective in treating pain and reducing disability. However, reports of cardiac events associated with triptan ingestion have led to concerns about its use in the face of possible cardiac disease.


OBJECTIVE
Should a patient without known cardiovascular disease (CAD) and moderately severe to severe migraines undergo cardiovascular testing prior to the initiation of triptan therapy?


METHODS
A Markov model of migraine and cardiac disease using DATA 4.0. Three strategies were compared: (1) use triptans without further evaluation (TREAT); (2) test, then treat if negative (TEST); and (3) avoid triptans (NOTRIPTAN). Triptans were prohibited if a cardiac event occurred.


METHODS
Model inputs were derived from the literature and subjected to sensitivity analyses across all possible values.


METHODS
Markov cycle is 1 week.


RESULTS
The primary outcomes of interest were quality-adjusted life expectancy, in years (QALYs) and the impact of various cardiovascular risk levels on the preferred strategy.


RESULTS
For the base case results were TREAT 19.4 QALYs, TEST 19.2, NOTRIPTAN 19.1. When altering CAD probability: TREAT dominated from 0 to 87%, TEST 87% to 97%, and NOTRIPTAN above 97%. Results were robust during sensitivity analyses.


CONCLUSIONS
This analysis suggests that even for individuals with a relatively high risk of CAD it is not beneficial to perform cardiac testing, nor to avoid triptans. The exact level of cardiac risk at which testing should be considered is probably at or above 87%.
Orlando
Lori A
LA
Duke University Medical Center, Durham VA, NC, USA.
Matchar
David B
DB
D002318:Cardiovascular Diseases / Q000139:chemically induced*; D006801:Humans; D008390:Markov Chains; D008881:Migraine Disorders / Q000188:drug therapy*; D008962:Models, Theoretical; D012307:Risk Factors; D017366:Serotonin Receptor Agonists / Q000009:adverse effects* / Q000627:therapeutic use
D017366:Serotonin Receptor Agonists