Navigating Contraindications in Real Life

Stephen D. Silberstein, MD

The importance of prescribing not only effective, but safe treatments for patients with neurological disorders is paramount. I’m confident that my colleagues in neurology would agree that weighing the benefits and risks of a particular therapy is a major and central component of their everyday practice, and it’s often the topic of conversation with a patient when initiating treatment for a disorder or making adjustments to the treatment plan throughout the course of disease.

Certainly, contraindications exist for a reason: They help us avoid introducing unnecessary risk and adverse effects in a person whose health is already compromised. However, in some cases, stated contraindications, which are typically established because those patient populations were not studied in clinical trials or an issue came to light in trials, may overly limit the use of what is otherwise a very effective and generally safe medication.

In headache medicine, we see this trend with triptans, which are generally contraindicated in patients with cardio- or cerebrovascular disease.¹ Although triptans, which are highly effective for the treatment of acute migraine, have been on the market for nearly 30 years, they are grossly underutilized due to a fear of exacerbating vascular events. This fear is not unfounded, as patients with headache and migraine are known to be at an increased risk for ischemic events,² but what is perhaps more concerning is how this fear can paralyze our ability to take further action for our patients.

In my practice, if a patient with episodic migraine—who would likely benefit from treatment with triptans—comes to me with uncontrolled hypertension, I do not hesitate to refer that patient back to their internist or a cardiologist to get their hypertension under control, after which I would feel more comfortable prescribing them a triptan.

When confronted with these situations, we should take a step back to evaluate what the real-life implications are. Are the contraindications realistic? Are they predictive of increased risk, beyond the risk that you would expect anyway?

If the answers to those questions are concerning, then I encourage you to reach out and incorporate the opinions of another specialist who can perform a dedicated evaluation to address your concerns, and in turn help you make a more educated decision for your patient.

It’s important that we look at contraindications not as a hard stop, but as a reason to further explore a patient’s medical history and improve their overall health.

REFERENCES

1. Loder E. Triptan therapy in migraine. N Engl J Med. 2010;363(1):63-70. doi: 10.1056/NEJMct0910887.

2. Scher AI, Terwindt GM, Picavet HS, Verschuren WM, Ferrari MD, Launer LJ. Cardiovascular risk factors and migraine: the GEM population-based study [comment in Neurology. 2005;65(10):1683; author reply 1683]. Neurology. 2005;64(4):614-620. doi: 10.1212/01.WNL.0000151857.43225.49.