Reduction in the therapeutic intensity of abortive migraine drug use during ACE inhibition therapy—a pilot study

Abstract

SUMMARYIntroduction Since a few case reports have demonstrated some beneficial effects of angiotensin converting enzyme (ACE) inhibitors in migraine prevention, we were interested in studying the impact of ACE inhibitors and angiotensin II receptor antagonists (Ang II) on the consumption of specific abortive migraine drugs and, therefore, indirectly on the frequency of migraine attacks. Methods Data from a large prescription database involving 95 patients initiating a specific abortive migraine drug (ergotamine or a triptan) and subsequently treated with either an ACE inhibitor or angiotensin receptor antagonist (index group: ACE/Ang II) or diuretic (reference group) were analysed. The effects of ACE/Ang II inhibition as well as diuretic therapy on reducing the frequency of migraine attacks were assessed by measuring the mean consumption of abortive migraine drug use, in DDDs per month ('therapeutic intensity'), before, during and after ACE/Ang II or diuretic therapy. A 'therapeutic fluctuation intensity estimate' of abortive migraine drug use for all patients was likewise calculated. Results On an individual level, the therapeutic intensity (TI) fluctuation estimate, 'during' relative to 'before' ACE diuretic therapy, was significantly larger for the ACE/Ang II group (62% reduction) than for the diuretic group (24% reduction) ( p ¼ 0.02). For patients who continued abortive migraine drug use during and after ACE/Ang II or diuretic therapy, a significantly larger reduction in this estimate was observed during ACE/Ang II inhibition (68.9%) compared to during diuretic therapy (10.5% increase) ( p ¼ 0.004). The TI fluctuation estimate, after relative to 'during', had increased by 50.3% after ACE/Ang II inhibition and had reduced by 22.2% after diuretic treatment ( p ¼ 0.1). Conclusions A clear reduction in the TI of abortive migraine drug use during the use of ACE inhibitors as compared to diuretic treatment was observed. Our findings may indirectly support a positive effect of ACE/Ang II inhibition on the frequency and severity of migraine attacks, as observed in other studies and reports.

New drugs for migraine

“…Additional proof of efficacy of these classes of drugs in migraine is by open studies for ACEIs [65–67] and by a study on migraine among hypertensive patients for candesartan [68]. Also, there is circumstantial evidence that the effect of candesartan may be a class effect of the ARBs since a large pharmacoepidemiologic study showed decreased use of triptans when patients started using an ACEI or an ARB of any type [69], and a meta-analysis of RCTs with ARBs used for other indications showed that headache as a side effect was lower in the ARB group than in the placebo group, irrespective of the type of ARB [70]. The mechanism for the antimigrainous action of these drugs is not known, but it is most certainly not related to decrease in the blood pressure.…”

Angiotensin I‐Converting Enzyme Gene (I/D) Polymorphism in Patients With Migraine

“…No consensus about the pathogenesis or treatment of migraine exists, although research on these topics continues. Neurogenic, vascular, and humoral factors may contribute to the development of migraine . However, none of these clearly explains the pathogenesis of migraine.…”

Polymorphisms in the Renin‐Angiotensin System and Migraine in Women

“…For example, population‐based studies have reported an association between migraine, in particular migraine with aura, and CVD 24 and the RAS plays an important role in the pathophysiology of CVD 21 . In addition, clinical trials have suggested that ACE inhibitors 10,11 and AT1 receptor blockers 12,13 may be effective in migraine prophylaxis. However, as with other migraine preventives only about 50% of patients benefit.…”