A contraindicated headache prescription

History and treatment

A 59-year-old female patient with a history of ischaemic heart disease and myocardial infarction saw her GP, complaining of headache and facial pain. The GP correctly diagnosed migraine, and prescribed sumatriptan succinate tablets. He asked the patient to come back in two days, which she did, reporting that the headaches were greatly improved. The GP advised using the sumatriptan sparingly.

Six months later, the patient was admitted to hospital with left ventricular failure. It was noted that her angina had been getting worse over the past few months. On discharge from hospital, she saw her GP again about her migraine. Further sumatriptan tablets were prescribed.

Soon after taking the first dose, the patient began to sweat and had further chest pain. She was admitted to hospital and diagnosed with unstable angina and non-ST segment change myocardial infarction. It was thought that this had been precipitated by the sumatriptan tablets.

Both the BNF and the data sheet advise that sumatriptan is contraindicated in coronary artery disease.

When the GP learned of his oversight, he visited the patient soon after her discharge to apologise for prescribing inappropriately. The patient went on to have cardiac catheterisation, which showed severe three-vessel disease and left ventricular dysfunction, and she subsequently underwent a coronary artery bypass graft.

A surprise claim

Two years later, the member was surprised to receive a solicitor's letter, intimating a claim for damages for the inappropriate prescription of sumatriptan. It was alleged that, as a result, the patient had suffered worsening of her angina, and required admission to hospital with a small myocardial infarction.

The patient's coronary artery bypass graft was not attributed to the prescription and neither was the permanent damage to the left ventricle. It was, however, alleged that the inappropriate prescription had made a 10 per cent contribution to the patient's poor left ventricular function, due to the myocardial infarction, and that therefore a 10 per cent contribution to the patient’s current level of care was appropriate. By this time the patient was considerably incapacitated by left ventricular failure.

A minimal settlement

The claim was settled for a small amount to reflect the additional worsening of the angina over the six-month period and the hospital admission. It was not accepted that there should be any contribution to the patient's current care, as she would have needed this in any case.

Interestingly, it was noted in the hospital records that sumatriptan had also been prescribed by the admitting SHO on the patient's admission with left ventricular failure, although it had been discontinued after just one dose, presumably when it was realised that it was contraindicated for this patient.

This page was correct at publication on 26/04/2006. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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