From the Research
For patients with a history of coronary artery disease (CAD), the safest abortive migraine therapy is typically non-triptan, non-ergot medications, with acetaminophen (Tylenol) at 1000 mg per dose being generally considered first-line due to its lack of vasoconstrictive effects that could exacerbate cardiac issues. When considering the management of migraines in patients with CAD, it's crucial to prioritize treatments that do not increase the risk of cardiovascular events.
- Non-triptan, non-ergot medications are preferred due to their safer cardiovascular profile.
- Acetaminophen is often the first choice because it does not have the vasoconstrictive effects associated with triptans and ergots, which could worsen CAD 1.
- NSAIDs like ibuprofen (400-600 mg) or naproxen sodium (500-550 mg) can be used cautiously in patients with stable CAD, provided there are no contraindications such as heart failure or renal disease.
- Antiemetics such as metoclopramide (10 mg) or prochlorperazine (10 mg) can help with nausea and may have independent analgesic effects.
- Neuromodulatory devices like remote electrical neurostimulation (Nerivio) or supraorbital transcutaneous stimulation (Cefaly) offer non-pharmacological alternatives without cardiovascular effects.
- For moderate to severe migraines, newer options such as gepants (e.g., ubrogepant, rimegepant) and ditans (e.g., lasmiditan) are considered safer for CAD patients as they do not cause vasoconstriction, although they may have other side effects or restrictions, such as driving warnings for ditans 2, 3. It's essential to avoid triptans and ergots in CAD patients due to their potential to trigger cardiac events through vasoconstriction, emphasizing the need for careful selection of migraine therapies in this population 4, 5.