Fifty-seven patients (48%) underwent echocardiography with Doppler flow studies a minimum of 9 months after the onset of daily triptan use. The echocardiogram was abnormal in 10 patients (18%), but none of the abnormalities were considered related to the use of triptans. Of these PF2341066 patients, 6 (10%) had mitral valve prolapse; the other abnormalities were mitral regurgitation, enlarged aorta, mild right ventricular enlargement, and aortic regurgitation, each occurring in 1 patient. Twenty patients (17%) had cardiac stress tests performed for various reasons, unrelated to the triptan usage, and all were normal.

One patient had a cardiac catheterization, which was also normal. By comparison, there are a number of serious safety concerns with daily or almost daily use of opioids, opioid combinations,[8] or butalbital combinations.[9] In addition, the combinations may contain acetaminophen, which is the leading cause of death from over-the-counter medications, and over a period of a decade resulted in 1567 deaths from liver failure due to accidental selleck chemical overdoses.[10] With regard to the indications for daily or near-daily triptan use, it is not an established treatment and, therefore, there are no specific indications.

In addition, as Robbins and Maides[6] observed and what confirms my own experience, patients are not deliberately placed on daily triptan but rather discover, on their own, that the triptan is highly effective for the treatment of their daily headaches. Under those circumstances, it is hard to argue against the daily or almost-daily use of triptans, particularly if there are no indications of medication-overuse headache or safety concerns. The safety issue is addressed above, and that of medication-overuse headache still needs to be addressed. Specifically related to MCE triptans, medication-overuse headache

is defined by the International Headache Society as triptan use on 10 or more days per month for more than 3 months.[11] Of course, this definition is too simplistic to be true, is entirely arbitrary, and lacks appreciation of the complexity of what medication-overuse headache is all about. As I recently wrote in an opinion article in Headache,[12] the consideration of the clinical picture seems to have disappeared from the scene, not only for the diagnosis of medication-overuse headache but also, for example, for that of hemicrania continua, a condition I described with Ottar Sjaastad in 1984.[13] In medication-overuse headache, the clinical picture is that of the patient suffering from daily or almost-daily headaches, often tremendously, despite excessive use of abortive medications, a paradox that patients and physicians alike often still have a hard time comprehending.