A Retrospective Analysis of Triptan and DHE Use for Basilar and Hemiplegic Migraine

Paul G. Mathew, MD, FAHS; Regina Krel, MD; Bhuvin Buddhdev, MD; Hossein Ansari, MD; Shivang G. Joshi, MD, MPH, RPh; Warren D. Spinner, DO; Brad C. Klein, MD, MBA


Headache. 2016;56(5):841-848. 

In This Article

Medicolegal Implications

When considering the risk to benefit ratio of any treatment, a black box warning can certainly deter a physician from prescribing a treatment despite a small actual risk. In such cases, there are ways to mitigate risk on the part of the physician.

  • Avoid use of the term BM in patient documentation, and instead use migraine with brainstem aura. Another option would be to include the symptoms as separate issues in the patient's chart. For example, instead of documenting migraine with brainstem aura, one could document migraine with aura and vertigo as two separate problems.

  • The use of an informed consent document may also be reasonable when administering a triptan or DHE to a patient in this population. Such documents can be quite extensive, but should include the following elements in some form:

(Patient Name) carries a diagnosis of Hemiplegic migraine/migraine with brainstem aura. He/She has failed several medication trials aimed at controlling his/her headaches. Medications which have been either poorly tolerated or ineffective are listed in the attached clinical documentation. I reviewed with (Patient Name) the studies, which have been completed to date demonstrating the use of (triptan name/DHE) for the treatment of HM/migraine with brainstem aura without any clear adverse cardiovascular events (stroke, heart attack, etc) associated directly with administration (references 9–11 and this study). I also shared with (Patient Name) my anecdotal experience with (triptan name/DHE) use from patients in my clinical practice. I recommend the use of (triptan name/DHE) for (Patient Name) and feel that given his/her previous inadequate response to treatment that it is medically necessary. By signing this document, (Patient Name) acknowledges the risks and benefits of (triptan name/DHE) use, and wishes to proceed with treatment.

It should be noted that the use of this template in any form is not a guarantee of protection in the event that there is any ensuing litigation after using triptans or DHE in this patient population.