Contraindications for Triptans (Serotonin Receptor Agonists)
Triptans are absolutely contraindicated in patients with ischemic heart disease, vasospastic coronary disease, previous myocardial infarction, stroke, transient ischemic attack (TIA), peripheral vascular disease, or uncontrolled hypertension. 1, 2
Cardiovascular Contraindications
Triptans should not be used in patients with:
- Ischemic heart disease (coronary artery disease)
- History of myocardial infarction
- Prinzmetal's angina/vasospastic coronary disease
- Stroke or transient ischemic attack (TIA)
- Peripheral vascular disease
- Uncontrolled hypertension 1, 2, 3
These contraindications are based on triptans' vasoconstrictive properties that can potentially exacerbate cardiovascular conditions. Recent research suggests that triptan initiation is associated with higher risk of ischemic stroke and myocardial infarction, particularly in patients with pre-existing cardiovascular risk factors 4.
Other Contraindications
Concurrent use of ergotamine-containing medications: Due to additive vasospastic effects, triptans should not be used within 24 hours of ergot-containing or ergot-type medications (like dihydroergotamine or methysergide) 2
MAO-A inhibitors: Use of triptans in patients receiving MAO-A inhibitors is contraindicated due to increased systemic exposure (7-fold) 2
Other 5-HT1 agonists: Co-administration of multiple triptans or other 5-HT1 agonists within 24 hours is contraindicated due to potential additive vasospastic effects 2
Pregnancy: Triptans should not be used during pregnancy unless the potential benefit justifies the potential risk to the fetus 3
Hemiplegic or basilar migraine: These migraine subtypes have traditionally been considered contraindications for triptan use
Warnings and Precautions
While not absolute contraindications, caution is advised in these situations:
Multiple cardiovascular risk factors: Patients with ≥2 cardiovascular risk factors should be evaluated for subclinical coronary artery disease before receiving triptans 5
Risk of serotonin syndrome: Caution when using triptans with SSRIs, SNRIs, TCAs, and MAO inhibitors due to risk of serotonin syndrome 2, 3
History of seizures: Triptans should be used with caution in patients with epilepsy or conditions associated with a lowered seizure threshold 2
Hepatic or renal impairment: Dose adjustment may be required
Age over 65 years: Increased cardiovascular risk necessitates careful evaluation before triptan use
Clinical Implications
The contraindications to triptans affect a substantial portion of migraine patients. Research indicates that approximately 20% of migraine patients have cardiovascular conditions that specifically contraindicate triptan treatment, and an additional 25% have multiple cardiovascular risk factors that warrant caution 5.
Despite these contraindications, some studies suggest that vascular comorbidity is comparable in users and non-users of triptans over age 50, indicating that careful selection of patients without absolute contraindications may allow safe use in older populations 6.
Alternative Options for Contraindicated Patients
For patients with contraindications to triptans, consider:
- NSAIDs (diclofenac potassium, ibuprofen, naproxen sodium)
- CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant
- Ditans (lasmiditan)
- Non-pharmacological approaches 7
Remember that all triptans are contraindicated in the presence of cardiovascular disease 8, and the risk-benefit assessment should be carefully considered in patients with multiple cardiovascular risk factors.