Rethinking Our Cardiovascular Risk Assessment in the Younger Female Migraine Population

Clinicians treating migraine headaches face challenges when prescribing pharmacologic therapies with vasoconstrictive properties in patients with vascular risk factors, as presented by the 2 cases described by Leroux et al. Adverse ischemic vascular events with triptans are mostly cardiac events, although both expert opinion and clinical data reviews are overall reassuring. Our knowledge on the distribution of cardiovascular disease in migraine patients stems from the remarkable database of the American Migraine Prevalence and Prevention Study. In patients who we consider at least at moderate risk of a cardiovascular complication, common practice is to perform non-invasive cardiac testing, such as an EKG exercise stress test, prior to prescribing a vasoconstrictive agent. However, a limitation in headache medicine is that we largely base our risk assessment on traditional risk factors, predominantly those identified by the Framingham Heart Study, including diabetes, cigarette smoking, hypertension, and dyslipidemia. This multivariate risk prediction model was initially developed in 1948, then revised based on a cohort of over 8000 participants. The Framingham cohort is not, however, representative of the migraine population seen in routine clinical practice and is unsuitable as a screening tool for this purpose. For example, participants of the Framingham cohort were aged between 30 and 74 years old (mean age, 49 years) but the peak prevalence of migraine begins as early as 25 years of age. Therefore, the validity of the Framingham risk score (FRS), a tool that most of us rely on when deciding on the safety of prescribing vasoconstrictive agents, is poorly applicable to certain populations, including women under 30 years old. It has further limitations when taking into consideration ethnicity, for example, in young Aboriginal women, in whom the observed coronary heart disease rate is up to 30 times the predicted estimate. We should also question the use of the FRS as a screening tool to guide our choice of pharmacological therapy for migraines because it was designed to predict the risk of developing traditional atherosclerotic cardiovascular disease in the future, not to actually diagnose prevalent disease. In the absence of anginal symptoms, the pretest likelihood of detecting obstructive coronary disease is very low, mostly in young women, and the FRS is of little value in this context. Improving our understanding of cardiovascular risk assessment in the younger female population is to an even greater extent important considering the rise in hospitalisation and mortality due to acute coronary events in women under 50 years old, in striking contrast with the observed improvements in cardiovascular outcomes in post-menopausal women. Considering the explosion of novel calcitonin generelated peptide (CGRP) blocking agents in our therapeutic armamentarium, as well as expert concerns that the distal segments of coronary arteries are more dependent on CGRP compensatory vasodilation in women, the issue of raising awareness on cardiovascular Headache doi: 10.1111/head.13809 © 2020 American Headache Society Published by Wiley Periodicals, Inc. ISSN 0017-8748