2026 Southeastern Residency Conference

Optimizing Migraine Management in Veterans: A Pharmacist-Led Review of Triptan Use in Primary Care Clinics
Justin Barnett, Jessica Parks, Stephanie Hopkins, Karyn Fabo
Fayetteville NC VA Coastal Health Care System – Fayetteville, NC

Background: Acute migraine headaches affect approximately 16% of the United States population. Triptans (e.g., sumatriptan, rizatriptan, etc.) are often the first-line option for acute migraine management. Triptans provide symptom relief by promoting vasoconstriction of intracranial blood vessels, and while this mechanism is the primary source of therapeutic benefit, it also increases cardiovascular risks, especially coronary vasospasm. As a result, the triptan class is contraindicated in patients with a history of cardiovascular disease, and use should be limited in patients with risk factors for cardiovascular disease. Nationwide prescribing patterns suggest that nearly 14% of patients using triptans meet at least one contraindication.


Methods: This quality improvement initiative identified adult Veterans at a Veterans Affairs (VA) Health Care Center who had an active prescription for a triptan medication. Patients qualified for review if they were managed by one of six designated primary care clinics and were disqualified if their migraine disorder was actively managed by a VA or private-sector neurologist.

Contraindications (including ischemic heart disease, arrhythmias, uncontrolled hypertension, history of gastrointestinal ischemia, history of stroke, peripheral vascular disease, and structural heart disease) and cardiovascular risk factors (including hypertension, hyperlipidemia, diabetes mellitus, hepatic or renal failure, obesity, age >65 years, and current tobacco use) were identified via electronic health record (EHR) review. The primary author attempted telephone contact with each identified Veteran to reconcile any potential discrepancies in EHR documentation.

At the conclusion of the patient encounter, the primary investigator recommended the following: no intervention, referral by primary care provider (PCP) to neurology service, referral by PCP to cardiology service, discontinuation of triptan prescription, or referral directly to clinical pharmacist practitioner (CPP) for chronic disease state management. Recommendations were assessed as “accepted” or “not accepted”, and the results were analyzed using descriptive statistics. Findings will be communicated to the designated primary care clinics in order to improve future prescribing practices.


Results: Of the 86 patients identified, 13 patients (15.1%) had at least one contraindication to triptan use, and the most frequent contraindication was uncontrolled hypertension (n=9, 10.4%). Interventions were recommended for 33 Veterans but were accepted for only 17. The most frequently recommended intervention was for a neurology consult (n=20). The most frequently accepted intervention (n=10) was for referral to a CPP for management of chronic disease states that can increase cardiovascular risk.


Conclusions: Data from this quality improvement initiative demonstrate that pharmacists should be actively engaged in monitoring triptans and counseling patients to ensure those with contraindications do not use this class of medications.