5-HT2 receptor antagonists and migraine therapy

5-Hydroxytryptamine (5-HT; serotonin) has been implicated in the pathophysiology of migraine, and several drugs with potent 5-HT₂ receptor blocking activity (methysergide, pizotifen, cyproheptadine and mianserin) have been recognized as being clinically effective in migraine prophylaxis, although the selective 5-HT₂ receptor antagonist ketanserin (the principal agent used to identify 5-HT₂ receptor-mediated actions) seems to be ineffective in migraine. Pizotifen is the most widely used 5-HT₂ receptor antagonist in migraine prophylaxis, because of its superior efficacy compared with cyproheptadine, and because the incidence and severity of adverse effects with pizotifen is lower compared with methysergide and mianserin. These agents have additional antagonistic effects at histamine H₁, muscarinic cholinergic, ₁-adrenergic, ₂-adrenergic and dopamine receptors, but drugs which are selective for these non-5-HT receptors appear to be of no benefit in migraine. Actions mediated by 5-HT₂ receptors which could be of relevance to migraine comprise cranial vasoconstriction, increased cranial capillary permeability and platelet aggregation, and some central nervous system effects and neuroendocrine functions. Although pizotifen, cyproheptadine and mianserin are considered to be relatively specific for 5-HT₂ receptors, these agents and methysergide all share a high affinity for 5-HT_1C binding sites; ketanserin, however, has little affinity for these sites, thus activation of 5-HT_1C receptors may be an important step in the pathogenesis of migraine. It is not yet known which 5-HT_1C receptor-mediated actions of 5-HT are relevant to migraine, but some behavioural actions and cranial vasodilatation via release of endothelium-derived relaxing factor may be involved. If 5-HT_1C rather than 5-HT₂ receptor-mediated actions are important, then other 5-HT₂ receptor antagonists with a high affinity at 5-HT_1C binding sites, such as LY 53857, metergoline, mesulergine, ritanserin and SCH 23390, may also prove to be effective in migraine. The efficacy of methysergide may also depend on other 5-HT₁-like receptor-mediated actions such as cranial vasoconstriction, and inhibition of cranial vascular neurogenic inflammation. The efficacy of these agents implies that 5-HT is causally involved in at least some of the underlying pathophysiology of migraine.