What are the treatment options for migraine in a patient with spontaneous coronary artery dissection (SCAD), considering the risks of triptans and calcitonin gene-related peptide (CGRP) inhibitors like erenumab (aimovig)?

Treatment Options for Migraine in Patients with Spontaneous Coronary Artery Dissection (SCAD)

For patients with SCAD, non-vasoconstrictive migraine treatments should be prioritized, avoiding triptans and using CGRP inhibitors with caution due to potential cardiovascular risks. 1

Understanding SCAD and Treatment Considerations

SCAD is a non-atherosclerotic separation of coronary arterial layers creating a false lumen and downstream myocardial ischemia, occurring predominantly in women under 60 years (22-35% of ACS cases in this demographic). 1

Key characteristics of SCAD:

• Affects women in over 90% of cases 2
• Often precipitated by emotional or physical stress 1
• Associated with fibromuscular dysplasia in up to 72% of cases 1
• Higher prevalence in patients with history of anxiety, depression, or previous neuropsychiatric disorders 1

Safe Migraine Treatment Options for SCAD Patients

First-line Options:

• Beta-blockers - Strongly recommended as they reduce risk of recurrent SCAD while also providing migraine prophylaxis 1, 2
• Anti-hypertensive medications - Aggressive blood pressure control is recommended as hypertension is an independent predictor of recurrent SCAD 1, 2
• Non-vasoactive analgesics - Including acetaminophen and NSAIDs for acute treatment 3, 4

Second-line Options:

• Anticonvulsants (topiramate, valproate) for migraine prophylaxis 5
• Antidepressants (amitriptyline, venlafaxine) for migraine prevention 4
• Botulinum toxin injections for chronic migraine 5

Treatments to Avoid or Use with Caution

Contraindicated:

• Triptans - Should be avoided due to their vasoconstrictive properties that could potentially worsen SCAD 3, 5
• Ergot derivatives - Contraindicated due to potent vasoconstrictive effects 5
• Fibrinolytics and anticoagulants - Could favor hematoma propagation in SCAD 3

Use with Caution:

• CGRP inhibitors - Erenumab and other monoclonal antibodies targeting CGRP should be used with extreme caution due to potential cardiovascular effects 5
• Potent P2Y12 inhibitors (ticagrelor, prasugrel) - Should be avoided in SCAD patients 3

Management Algorithm for Migraine in SCAD Patients

1. For prophylaxis:

   • Start with beta-blockers (first choice as they also reduce SCAD recurrence) 2
   • If inadequate response, add or switch to anticonvulsants or antidepressants 5
   • Consider botulinum toxin for refractory chronic migraine 5

2. For acute attacks:

   • Begin with acetaminophen or NSAIDs 4
   • For moderate-severe attacks unresponsive to simple analgesics, consider:
     • Anti-emetics for associated nausea 5
     • Non-vasoactive muscle relaxants if tension component present 4

3. Lifestyle modifications:

   • Stress management techniques (SCAD is often precipitated by stress) 1
   • Regular sleep schedule and adequate hydration 5
   • Identification and avoidance of migraine triggers 5

Common Pitfalls and Caveats

• Misdiagnosis of chest pain - Migraine and SCAD symptoms can sometimes overlap; careful evaluation is needed to distinguish between migraine-associated chest discomfort and actual cardiac symptoms 6
• Overuse of NSAIDs - Can lead to medication overuse headache and gastrointestinal complications 5
• Inadequate follow-up - SCAD patients with migraines should be monitored closely as both conditions can recur 2
• Undertreatment of pain - Fear of using medications may lead to inadequate pain control; non-vasoactive options should be optimized 4

Remember that SCAD patients require a conservative approach to treatment, with careful consideration of cardiovascular risks when selecting migraine therapies 1.