The management and monitoring of methysergide-induced fibrosis

Objective: The goal of this article is to review clinical features, pathogenesis, and management of methysergide-induced fibrosis. Data Sources: Review of the literature for methysergide induced fibrosis. Study Selection: MEDLINE search from 1966 through 1997; personal case on methysergide induced retroperitoneal fibrosis. Data Extraction: The studies included were critically evaluated by the two authors. Data Synthesis and Conclusion: Methysergide is a frequently used drug for prophylaxis of migraine headaches. The fibrotic side effects associated with its use are variable in intensity and distribution. If unrecognized, the process may become irreversible with serious consequences. The clinical course may be slow and indolent, or rapid and progressive. Fibrosis commonly affects the retroperitoneal structures. Less common sites of affliction include pulmonary, mediastinal and thoracic structures. The pathogenesis is not clear but postulated mechanisms include: excessive circulating serotonin effect, auto-immune inflammation, periaortitis related to ceroid release after vasoconstriction, and, protein- rich extravascular leak resulting in fibrosis and collagen formation. Careful and vigilant follow-up of patients using this drug is critical to ensure prevention and limitation of the fibrotic complications. The need for and the effectiveness of 'drug-breaks' is not clear and patients who have good relief from migraine headaches with methysergide may be reluctant to cease the drug. Hence, the need for regular clinical reviews is apparent, including the simple screening pathology tests such as ESR and C-reactive protein. It is mandatory to immediately cease the drug if there is any suggestion of an ongoing inflammation and/or fibrosis.