Narrative review of migraine management in patients with renal or hepatic disease

Abstract

Objectives/BackgroundTreatment of migraine in the setting of either renal or hepatic disease can be daunting for clinicians. Not only does the method of metabolism have to be considered, but also the method of elimination/excretion of the parent drug and any active or toxic metabolites. Furthermore, it is difficult to think about liver or kidney disease in isolation, as liver disease can sometimes contribute to impaired renal function and renal disease can sometimes impair hepatic metabolism, through the cytochrome P450 system.MethodsA detailed search for terms related to liver disease, renal disease, and migraine management was performed in PubMed, Ovid Medline, Embase, and the Cochrane Library.For each medication, product labels were retrieved and reviewed using the US FDA website, with additional review of IBM Micromedex, LiverTox, and the Renal Drug Handbook.ResultsThis manuscript provides an overview of migraine drug metabolism and how it can be affected by liver and renal impairment. It reviews the standard terminology recommended by the US Food and Drug Administration for the different stages of hepatic and renal failure. The available evidence regarding the use of abortive and preventative medicines in the setting of organ failure is discussed in detail, including more recent therapies such as lasmiditan, gepants, and calcitonin gene‐related peptide antibodies.ConclusionsFor acute therapy, the use of NSAIDS should be limited, as these carry risk for both severe hepatic and renal disease. Triptans can be selectively used, often with dose guideline adjustments. Ubrogepant may be used in severe hepatic disease with dose adjustment and lasmiditan can be used in end stage renal disease. Though non‐medicine strategies may be the most reasonable initial approach, many preventative medications can be used in the setting of hepatic and renal disease, often with dose adjustment. This review provides tables of guidelines, including reduced dosing recommendations, for the use of abortive and preventative migraine medications in hepatic and renal failure.

Associations between Chronic Kidney Disease and Migraine Incidence: Findings from a Korean Longitudinal Big Data Study

“…Through this analysis, our study revealed a modest reduction of approximately 11% in the likeli-hood of migraine occurrence among CKD patients, especially among those with specific demographic characteristics such as older adults (aged 70 years or older), females, and those without hypertension. Considering the intricate challenges associated with managing migraines in individuals with renal disease [19], these findings may underscore the need for careful follow-up and preventive management for individuals lacking the identified protective factors, including male CKD patients under the age of 70 with hypertension. The observed modest reduction in migraine incidence among CKD patients may hold clinical significance, as it may offer insights into potential avenues for migraine management in this population.…”

“…The CCI was employed as a continuous variable, encompassing a score ranging from 0, indicating the absence of comorbidities, to 29, representing the existence of diverse comorbidities [25,26]. The selection of covariates for adjustment was based on a review of the literature indicating potential confounders in the association between CKD and migraine incidence [2][3][4][5][17][18][19], ensuring a robust statistical analysis.…”

“…The specific link between CKD and migraines has been relatively underexplored in cohort studies, leading to conflicting findings [17,18]: a study from Taiwan reported a 22% enhanced risk of subsequent occurrence of CKD in the migraine group [17], while a study conducted in the UK population found no causal effect of migraines on the development of CKD [18]. Notably, these two cohort studies [17,18], along with the majority of previously published reviews exploring the relationship between these two conditions, have predominantly focused on the question of migraines as a risk factor for the initiation of CKD [5,17,19]. While headaches are commonly experienced by individuals with CKD [2], there is a notable lack of statistical evaluations within population-based studies that specifically investigate the relationship between CKD and incident migraines, raising questions about whether CKD may be one of the risk comorbidities inducing migraines in the Korean population.…”