441 Case Report Efficacy of Candesartan in the Treatment of Migraine in Hypertensive Patients Kiyoshi OWADA＊,＊＊ Triptans are usually administered for migraine, but cannot be given to patients with malfunctioning cardiac or cerebral vascular systems, which commonly accompany hypertension. This article focuses on 8 cases in which treatment with candesartan was successful in reducing both the incidence and severity of headache in hypertensive patients with migraine. The cases reported in this article showed a mean improvement in Mi- graine Disability Assessment score from 29.4 to 9 points and in blood pressure from 154.9/90.4 to 129.5/81.9 mmHg, suggesting that candesartan is an extremely attractive option for the treatment of mi- graine. Although recent studies have reported the efficacy of candesartan for treating migraine, there has been no description of its potential advantages over other prophylactic drugs. The present study included patients who could not tolerate triptans for whom triptans were contraindicated, several patients for whom other migraine prophylactic drugs showed little or no effect, and one patient for whom candesartan was pre- scribed initially for hypertension, but was also found to be therapeutic for migraines. Thus candesartan is considered to be a unique, attractive choice of prophylactic agent for migraine complicated by hyperten- sion. (Hypertens Res 2004; 27: 441–446) Key Words: angiotensin II receptor blocker, candesartan, migraine, hypertension ache intensity and duration when administered during the Introduction headache phase of the migraine (2, 3). However, these drugs are associated with specific adverse drug reactions (ADRs) Migraine affects approximately 10% of the adult population such as precordial distress and drowsiness, which cannot be and is particularly common in women. The disease principal- tolerated by some patients (4). A variety of drugs are cur- ly affects people in their prime working years, often striking rently being used for migraine prophylaxis, but none of them those who have experienced headache from childhood. Dur- are 100% successful in preventing migraine attacks. ing a migraine attack patients often must curtail their work Meanwhile, hypertension is recognized as a serious risk and other activities, so that the disease has high economic factor in the development of a variety of diseases and is the and social costs. Migraine differs considerably from tension single highest risk factor for stroke. Thus, antihypertensive headache, and is thought to be precipitated by excessive therapy is of extreme importance, and a variety of drugs are cerebral vasodilation and localized inflammation. Attacks, being used for this purpose. Today the angiotensin II recep- which occur from once or twice a month to several times a tor blockers (ARB) are coming into widespread use and have week, are characterized by repeated pulsating headache that attracted considerable attention due to their organ-protective persists for 4 to 48 h and then resolves without treatment. actions and other specific effects. Recent reports on the car- The classical migraine attack occurs in a characteristic man- dioprotective effects of the ARB candesartan have highlight- ner (1). Triptans provide noticeable improvement in head- ed the unique characteristics of this drug (5). More recently, From ＊the Department of Internal Medicine, Aoyama Hospital, Tokyo, Japan, and ＊＊Department of Neurology and Neurological Science, Tokyo Medical and Dental University, Tokyo, Japan. Address for Reprints: Kiyoshi Owada, M.D., Ph.D., Department of Internal Medicine, Aoyama Hospital, 5–53–3, Jingumae, Shibuya-ku, Tokyo 150– 0011, Japan. E-mail: [email protected] Received January 14, 2004; Accepted in revised form March 16, 2004. 442 Hypertens Res Vol. 27, No. 6 (2004) candesartan has also been reported to provide migraine pro- rience of precordial distress, her prescription was changed phylaxis (6), which has further sparked the interest of re- from sumatriptan to zolmitriptan. She currently takes searchers. The present case study series focuses on the thera- zolmitriptan about once a month, and is experiencing very peutic effects of candesartan in patients with hypertension few attacks. and migraine. Selected patient profiles are used as a basis for discussion of the significance of candesartan as an antimi- Case 3 graine drug. A 45-year-old man. The patient’s mother also had a history Case Studies of headaches. From 20 years of age the patient became aware of headache attacks, but took no medication. From the age of 38, attacks began to occur 1–3 times weekly. At the Case 1 age of 45 years, in addition to 4 or 5 attacks per month, he A 35-year-old woman. From the age of 18 years, the patient began to experience vomiting and dizziness along with began to notice occasional severe headaches, sometimes ac- headache and was referred to our department. NSAIDs were companied by vomiting. From April 2003, headaches in- prescribed and were somewhat effective against the creased to an average of 3 or 4 per month; the incidence in- headache attacks. Because he also complained of left chest creased again in June, and she was treated with nonsteroidal pain during the course of the disease, angina pectoris was anti-inflammatory drugs (NSAIDs). When the headaches be- suspected. In July his blood pressure was 174/86 mmHg, he came still more frequent she was referred to our hospital as was experiencing 1–2 migraines per week, and his MIDAS an outpatient. At her initial examination, her blood pressure was 16 points, so a prescription for candesartan 8 mg was was 148/88 mmHg and her Migraine Disability Assessment added to his treatment regimen. On his visit to the hospital in score (MIDAS) was 20 points. A regimen of sumatriptan August, his blood pressure was 152/86 mmHg, and the was prescribed. Although this treatment was somewhat ef- headache attacks that had plagued him for over 10 years fective, frequent headaches continued, so concomitant thera- had nearly vanished. To control his hypertension, he was py with candesartan 8 mg was added. Approximately 1 week switched to amlodipine 5 mg. In September his blood pres- after the start of candesartan administration, the frequency of sure was 140/100 mmHg, but he experienced a recurrence of her headaches declined, and in the second week her headache attacks 1–2 times weekly. When his antihyperten- headaches vanished completely. After 1 month, her blood sive medication was switched back to candesartan 8 mg, the pressure was successfully controlled at 118/88 mmHg, and headaches again vanished. His blood pressure is now being she experienced no headaches for several months under can- satisfactorily controlled at 134/68 mmHg. desartan administration. In August she underwent surgery for uterine myoma, with no recurrence of migraine attacks. Case 4 At present (October 2003), her migraines continue to be pre- vented by oral candesartan monotherapy. A 47-year-old woman. From 34 years of age, the patient no- ticed headaches occurring once or twice a week. These at- tacks began with scintillating scotoma, followed by intense Case 2 pulsating headache that persisted for 1 to 2 days. In 2003 the A 44-year-old woman. From the age of 15 years, the patient headaches worsened. The patient was referred to our hospital experienced occasional pain behind the eyes and pulsating for in-depth testing, and her condition was diagnosed as mi- unilateral headache, sometimes accompanied by vomiting. graine. On examination at our hospital, her blood pressure Beginning in November 2002, the pulsating headaches wors- was 144/76 mmHg and her MIDAS was 22 points. She was ened, sometimes persisting for 2–3 h, and sumatriptan was started on a course of sumatriptan, with NSAIDs to be taken prescribed. Although the drug relieved her headaches, she as needed, but the incidence of headache remained high. was unable to tolerate the precordial distress that she experi- Mild hypertension had been detected, so candesartan 8 mg enced with its use. When she presented at our hospital for was added to her treatment regimen, at which point her treatment for headache, her blood pressure was 150/90 headaches were reduced to approximately 1 per month. Im- mmHg and her MIDAS was 26 points. A MRI scan was provement was also noted in headache severity, to the extent performed, with results indicating a cerebral aneurysm in that the patient obtained adequate relief from NSAIDs alone, the anterior communicating artery, so intra-arterial coil without the use of sumatriptan. embolectomy was performed in January 2003. However, be- cause her migraine attacks persisted after surgery, candesar- Case 5 tan 8 mg therapy was initiated. This treatment brought a sharp reduction in headache frequency to approximately 1 A 54-year-old woman whose daughter also suffered from headache per month. The patient strongly desired treatment headaches. The patient first noticed headache in her 30s. At with a triptan, so out of consideration for her previous expe- onset, she experienced pain behind the eyes, and sometimes Owada: Candesartan for Migraine with Hypertension 443 the headaches became so severe that she could not open her Case 8 eyes. At 53 years of age she was examined at an urban uni- versity hospital and migraine was diagnosed. Sumatriptan A 49-year-old woman. From somewhat after 30 years of age, was prescribed. Lomerizine was tried for migraine prophy- the patient began experiencing 1 to 2 headaches per month. laxis, but with no effect. When she was referred to our hospi- The headaches began with pain behind the eyes, followed by tal for headache treatment, her MIDAS was 41 points. On intense pulsating pain. The patient took commercially avail- examination, her blood pressure was 156/108 mmHg, so able headache preparations such as aspirin 330 mg with di- treatment with candesartan 8 mg was initiated. The incidence aluminate or diclofenac sodium 25 mg, but these were inef- of headaches dropped to approximately 2 per month, and her fective, so she came to our hospital.