Narrative Review of Migraine Management in Patients With Renal or Hepatic Disease

Jennifer I. Stern MD; Shae Datta MD; Chia-Chun Chiang MD; Ivan Garza MD; Dorice L. Vieira MLS, MA, MPH; Carrie E. Robertson MD


Headache. 2023;63(1):9-24. 

In This Article

Abstract and Introduction


Objectives/Background: Treatment of migraine in the setting of either renal or hepatic disease can be daunting for clinicians. Not only does the method of metabolism have to be considered, but also the method of elimination/excretion of the parent drug and any active or toxic metabolites. Furthermore, it is difficult to think about liver or kidney disease in isolation, as liver disease can sometimes contribute to impaired renal function and renal disease can sometimes impair hepatic metabolism, through the cytochrome P450 system.

Methods: A detailed search for terms related to liver disease, renal disease, and migraine management was performed in PubMed, Ovid Medline, Embase, and the Cochrane Library.For each medication, product labels were retrieved and reviewed using the US FDA website, with additional review of IBM Micromedex, LiverTox, and the Renal Drug Handbook.

Results: This manuscript provides an overview of migraine drug metabolism and how it can be affected by liver and renal impairment. It reviews the standard terminology recommended by the US Food and Drug Administration for the different stages of hepatic and renal failure. The available evidence regarding the use of abortive and preventative medicines in the setting of organ failure is discussed in detail, including more recent therapies such as lasmiditan, gepants, and calcitonin gene-related peptide antibodies.

Conclusions: For acute therapy, the use of NSAIDS should be limited, as these carry risk for both severe hepatic and renal disease. Triptans can be selectively used, often with dose guideline adjustments. Ubrogepant may be used in severe hepatic disease with dose adjustment and lasmiditan can be used in end stage renal disease. Though non-medicine strategies may be the most reasonable initial approach, many preventative medications can be used in the setting of hepatic and renal disease, often with dose adjustment. This review provides tables of guidelines, including reduced dosing recommendations, for the use of abortive and preventative migraine medications in hepatic and renal failure.


It is not uncommon for patients to present for migraine management with comorbid hepatic or renal impairment, given the high prevalence of each of these diseases. While migraine affects an estimated 12% of the population,[1] chronic liver disease is estimated to occur in 1.5 billion people worldwide,[2] and the global prevalence of chronic kidney disease (CKD) has recently been estimated at 11%–13%.[3] Headache management in the setting of either hepatic or renal disease presents a challenge, as both can result in complex changes in biological and pharmacokinetic activities of headache medications and may increase risk for drug-related injury. This manuscript will provide a clinical guide and approach to headache management in patients with renal or hepatic disease.

Decisions on acute or preventative headache medicines for a patient with kidney or liver failure must consider not only how the drug's metabolism is changed depending on organ failure severity, but also whether the drug can create further organ toxicity or damage. This manuscript will therefore start with a brief overview of drug metabolism and how this may be affected by organ failure. Because the US Food and Drug Administration (US FDA) has recommended standard terminology be used for different stages of organ failure in pharmacokinetic studies, we will review the terminology recommended in the US FDA guidelines for industry. Each organ review will also be accompanied by some secondary headache considerations in the case of organ impairment. Finally, available evidence regarding the use of migraine acute and preventative medicines in the setting of organ failure will be discussed in detail.