Increased myogenic tone in skeletal muscle arterioles of diabetic rats. Possible role of increased activity of smooth muscle Ca2+ channels and protein kinase C.

OBJECTIVE: The diabetes mellitus-induced microangiopathy is still not clearly characterized. In this study we aimed to elucidate the effect of streptozotocin (STZ)-induced diabetes on myogenic response of isolated rat skeletal muscle arterioles and the mechanisms responsible for its alterations. METHODS: Male rats were divided into two groups: (1) control rats (C, plasma glucose: 6.4 +/- 0.5 mmol/l, n = 40) (2) diabetic rats (DM, 65 mg/kg STZ i.v., plasma glucose: 25.7 +/- 0.7 mmol/l, n = 40). Changes in diameter of isolated, cannulated gracilis skeletal muscle arterioles (approximately 130 microns in diameter) were measured by video-microscopy. RESULTS: Step increases in perfusion pressure (PP; from 10 to 140 mmHg) elicited significantly greater constrictions in DM than in C gracilis arterioles, in the presence of the endothelium (E). Also, a step increase in PP (from 40 to 100 mmHg) elicited greater and faster constrictions in DM vs. C arterioles. There were no significant differences in the pressure-passive diameter (in Ca2+ free solution) curves of arterioles. Dilations to acetylcholine were impaired in arterioles of DM as compared to those of C rats (EC50, C: 4.0 +/- 0.9 x 10(-9) mol/l, DM: 4.8 +/- 2.0 x 10(-8) mol/l (p < 0.01), and unaffected by inhibition of nitric oxide synthesis with L-NNA (10(-4) mol/l). Arteriolar constrictions to norepinephrine (NE) were significantly greater in DM compared to those of C rats (EC50, C: 6.2 +/- 0.6 x 10(-7) mol/l, DM: 8.0 +/- 2.0 x 10(-8) mol/l, p < 0.01) both in the presence and absence of E. In the absence of the E, constrictions to increases in pressure, or Ca2+ (0.25-7.5 mmol/l), or the voltage-dependent Ca(2+)-channel agonist Bay K 8644 (EC50; DM: 4.2 +/- 1.5 x 10(-10) mol/l, C: 1.7 +/- 0.8 x 10(-9) mol/l, p < 0.05) or the protein kinase C activator phorbol 12-myristate 13-acetate (PMA, EC50; DM: 6 +/- 2 x 10(-9) mol/l, C: 2 +/- 1 x 10(-8) mol/l, p < 0.05) were significantly greater in arterioles of DM compared to those of C rats. CONCLUSION: The novel findings of our study are that in diabetes mellitus the myogenic response of rat skeletal muscle arterioles is enhanced, which seems to be independent from the impaired endothelial function present simultaneously, and likely due to the increased activity of voltage-dependent Ca2+ channels and/or upregulation of protein kinase C in arteriolar smooth muscle.

Current trends in the development of new antidepressants.

Early antidepressant medications e.g. tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are effective because they enhance either noradrenergic or serotonergic mechanisms, or both. Unfortunately, these compounds block cholinergic, histaminergic and alpha-1-adrenergic receptor sites, interact with a number of other medications and bring about numerous undesirable side effects. Several chemically unrelated agents have been developed and introduced in the past decade to supplement the early antidepressants. These include selective inhibitors of the reuptake of serotonin (the selective serotonin reuptake inhibitors (SSRIs)) or noradrenaline (reboxetine) or both (SNRIs: milnacipran and venlafaxine), as well as drugs with distinct neurochemical profiles such as mirtazapine, nefazodone, moclobemide and tianeptine. All these newer compounds are the results of rational developmental strategies to find drugs that were as effective as the TCAs but of higher safety and tolerability profile. In spite of the remarkable structural diversity, most currently introduced antidepressants are monoamin based and modulating monoamine activity as a therapeutic strategy continues to dominate antidepressant research. It must be emphasised, however, that these newer antidepressants are far from the ideal ones, also resulting in undesirable side effects and requiring 2-6 weeks of treatment to produce therapeutic effect. Furthermore, approximately 30% of the population do not respond to current therapies. An important new development has been the emergence of potential novel mechanisms of action beyond the monoaminergic synapse. The results of recent novel developmental approaches have suggested that modulation of N-methyl-D-aspartate (NMDA), neuropeptide (substance P and corticotrophin-releasing factor) receptors and the intracellular messenger system may provide an entirely new set of potential therapeutic targets. This paper discusses the advances from monoamine-based treatment strategies and looks at the future developments in the treatment of depression.

Review of cardiovascular effects of fluoxetine, a selective serotonin reuptake inhibitor, compared to tricyclic antidepressants.

Fluoxetine is an antidepressant drug, a potent and specific inhibitor of serotonin reuptake (SSRI). Evidence suggests that being compared with tricyclic antidepressants, fluoxetine may cause significantly fewer anticholinergic, antihistaminergic and cardiotoxic side effects in the treatment of major depressive disorders. Chronic treatment with fluoxetine was not reported to affect the electrocardiogram (ECG). There is no clinical evidence of conduction delay and very little evidence of orthostatic hypotension. In the overdosed patients fewer cardiac symptoms were reported than with tricyclic antidepressants. However, dysrhythmia (atrial fibrillation and bradycardia) and syncope associated with fluoxetine treatment and overdose were reported. Although such reports have not been common, they do raise concerns. Thus we investigated the direct cardiovascular effects of the fluoxetine in isolated heart preparations and vessels of rats and rabbits. From 10(-6)M to 10(-4)M concentrations fluoxetine showed cardiodepressant and vasodilatory effects. These effects were similar to those of previously reported on tricyclic compounds. This review is a brief summary of possible cardiovascular effects of fluoxetine and other new SSRIs antidepressants from the literature based on experience of clinical studies and our experiments with fluoxetine on isolated rat and rabbit cardiac preparations and vessels. Possible explanations of the lower incidence of cardiovascular complications with fluoxetine in humans and cardiodepressant effects in vitro are discussed.

Speculations on difference between tricyclic and selective serotonin reuptake inhibitor antidepressants on their cardiac effects. Is there any?

The cardiovascular effects and toxicity of tricyclic antidepressants (TCAs) have been well documented in medical literature. The most common manifestation of such effects is slowing of intraventricular conduction, manifested by prolonged PR, QRS and QT intervals on the standard electrocardiogram (ECG) and postural hypotension. In contrast to TCAs, selective serotonin reuptake inhibitors (SSRIs), including fluoxetine and citalopram, are considered to cause less effect on cardiac impulse conduction. In addition, these compounds induced significantly less anticholinergic, antihistaminergic and cardiotoxic side-effects than TCAs. However, there is an increasing number of case reports on dysrhythmias, like atrial fibrillation or bradycardia and syncope associated with fluoxetine and another SSRI treatment and overdose. Although such reports have not been common, they do raise concerns. In cardiac tissues isolated from canine, rabbit, rat and guinea pig hearts we have found that fluoxetine and citalopram inhibited cardiac Na+ and Ca2+ channels. These direct cardiac electrophysiological effects were similar to those of observed for tricyclic antidepressants clomipramine and imipramine. The inhibition of cardiac Ca2+ and Na+ channels by fluoxetine may explain most cardiac side-effects observed occasionally with the drug and mild but significant bradycardia reported during chronic treatment. Our results suggest that fluoxetine and citalopram may have antiarrhythmic (class I + IV type), as well as proarrhythmic properties (due to impairment of atrioventricular or intraventricular conduction and shortening of repolarization). Taking all these into consideration, in depressed patients having also severe cardiac disorders, ECG control may be suggested during fluoxetine and probable another SSRI therapy. The primary goal of this review is to compare these direct cardiac effects of fluoxetine and citalopram to those of previously reported for TCAs. This paper also summarizes the recently observed effects of fluoxetine apparently not related to the blockage of 5-HT transporter based on literature.

Serotonin reuptake inhibitor, fluoxetine, dilates isolated skeletal muscle arterioles. Possible role of altered Ca2+ sensitivity.

1. Inhibitors of serotonin reuptake in the central nervous system, such as fluoxetine, may also affect the function of vascular tissues. Thus, we investigated the effect of fluoxetine on the vasomotor responses of isolated, pressurized arterioles of rat gracilis muscle (98 +/- 4 microns in diameter at 80 mmHg perfusion pressure). 2. We have found that increasing concentrations of fluoxetine dilated arterioles up to 155 +/- 5 microns with an EC50 of 2.5 +/- 0.5 x 10(-6) M. 3. Removal of the endothelium, application of 4-aminopyridine (4-AP, an inhibitor of aminopyridine sensitive K+ channels), or use of glibenclamide (an inhibitor of ATP-sensitive K+ channels) did not affect the vasodilator response to fluoxetine. 4. In the presence of 10(-6), 2 x 10(-6) or 10(-5) M fluoxetine noradrenaline (NA, 10(-9)-10(-5) M) and 5-hydroxytryptamine (5-HT, 10(-9)-10(-5)M)-induced constrictions were significantly attenuated resulting in concentration-dependent parallel rightward shifts of their dose-response curves (pA2 = 6.1 +/- 0.1 and 6.9 +/- 0.1, respectively). 5. Increasing concentrations of Ca2+ (10(-4) 3 x 10(-2) M) elicited arteriolar constrictions (up to approximately 30%), which were markedly reduced by 2 x 10(-6)M fluoxetine, whereas 10(-5)M fluoxetine practically abolished these responses. 6. In conclusion, fluoxetine, elicits substantial dilations of isolated skeletal muscle arterioles, a response which is not mediated by 4-AP- and ATP-sensitive K+ channels or endothelium-derived dilator factors. The findings that fluoxetine had a greater inhibitory effect on Ca2+ elicited constrictions than on responses to NA and 5-HT suggest that fluoxetine may inhibit Ca2+ channel(s) or interfere with the signal transduction by Ca2+ in the vascular smooth muscle cells.

Effect of dantrolene sodium on the transmembrane potentials and contractility of guinea pig atrial myocardium.

Dantrolene sodium (3 X 10(-4) M) exerted a biphasic effect on the mechanical and electrical activity of the isolated guinea pig left atrium. In the first phase, the drug increased the contractile force by about 200%, and prolonged the action potential duration. This transient positive inotropic effect was antagonized by D-600, a slow Ca2+ channel inhibitor. In the later phase, the drug gradually decreased the amplitude of contractions, shortened the action potential duration and induced contracture. Dantrolene sodium increased the rate of depolarization and overshoot of Ca2+ -mediated slow action potentials. The results suggest that dantrolene sodium increases the slow inward Ca2+ current, causing a positive inotropic effect in the atrial myocardium. The late negative inotropic effect of the drug could be due to a secondary inhibition of the slow inward Ca2+ current due to an increased intracellular free Ca2+ concentration as a consequence of other actions of the drug.

Modification of the cardiac transmembrane potentials and currents by polyamines.

Spermine up to 10(-5) M increased the resting potential (RP) and maximum rate of rise (Vmax) of the action potential (AP) and accelerated the initial (20, 50%) repolarization in isolated guinea-pig and cat atria. These effects were not modified by pindolol (4 X 10(-7) M) or atropine (3 X 10(-7) M) but were prevented by indomethacin (10(-6) M). The right papillary muscle of guinea-pig only showed the acceleration of repolarization while the other parameters were not changed. Spermine did not influence the inward membrane currents under voltage clamp conditions in frog sinoatrial fibers. Spermidine up to 10(-5) M increased RP, Vmax and the duration of AP in guinea pig papillary muscle. RP, Vmax and AP duration were moderately enhanced by spermidine in guinea pig atrium and were not changed in cat atrium. Spermidine was found to stimulate the inward membrane current. Its stimulatory effect was confined to the fast component of the inward current. Neither spermidine nor spermine were able to induce the Ca2+-dependent slow AP in 25 mM K+-depolarized atrium. It is suggested that polyamines influence cardiac membrane events which are responsible for AP and ionic currents.

Antagonism between adenosine and bromobenzoyl-methyladamantylamine, a K+-channel blocker, in atrial myocardium of guinea pig.

The effect of bromobenzoyl-methyladamantylamine (BMA) on the adenosine-induced changes in the electrical and mechanical activity of the atrial muscle, and the effect of adenosine on the slow action potentials induced by BMA in K+-depolarized atrial myocardium of guinea pig were studied. BMA was able to antagonize the adenosine-induced shortening of the action potential duration and negative inotropic effect. This action of BMA was potentiated by theophylline, and reduced by dipyridamole. Adenosine depressed the BMA-induced slow action potentials. The results suggest that there may be an antagonism between BMA and adenosine.

Inhibition of myocardial K+ channels by bromobenzoyl-methyladamantylamine, an adamantane derivative.

The effect of bromobenzoyl-methyladamantylamine (BMA) on transmembrane potentials and contractility of atrial and ventricular myocardium of guinea-pig and cat, as well as on transmembrane ionic currents of the frog atrial trabeculae was studied using conventional glass microelectrode and double sucrose-gap voltage clamp techniques. BMA markedly prolonged the action potential duration, depolarized the cell membrane, reduced the rate of rise of the action potential and exerted a positive inotropic effect on non-clamped myocardial preparations. The drug-induced pacemaker activity in ventricular working muscle of cat. Moreover, BMA antagonized the effects of the K+ channel activator acetylcholine in a dose-dependent manner. BMA was found to induce slow response action potentials in K+ -depolarized ventricular myocardium of guinea-pig. In voltage clamp experiments, BMA reduced the outward K+ current but had no effect on either rapid inward Na+ or slow inward Ca2+ currents. The results suggest that BMA is capable of selectively blocking the myocardial K+ channels.

Blockage of the fast sodium current by dimethindene in frog auricular fibres.

The effect of dimethindene (DMI) on action potential and fast inward Na current (INa) of frog atrial fibres was studied using double sucrose gap voltage-clamp technique. DMI reduced the amplitude and maximum rate of rise of the action potentials without altering the resting membrane potential. The drug inhibited the fast Na conductance in a concentration-dependent manner, without changing the reversal potential. The shape of the current-voltage curve along the voltage axis remained unchanged in the presence of DMI. The time to peak of the INa was not significantly altered by the drug whereas the rate of the INa inactivation (tau h) was slowed. DMI shifted the steady-state inactivation curve of INa (h infinity) to more negative potentials, and increased the reactivation time constant of the sodium system (tau r). The inhibition of INa was use-dependent. The results suggest that DMI interacts with the inactivation mechanism of the sodium channel of the frog myocardium, and explain its favourable antiarrhythmic activity.

Electrophysiological effects of fluoxetine in mammalian cardiac tissues.

Fluoxetine is a widely used antidepressant compound having selective serotonin reuptake inhibitor properties. In this study, the actions of fluoxetine were analyzed in guinea pig, rat, rabbit and canine ventricular myocardiac preparations using conventional microelectrode and whole cell voltage clamp techniques. Low concentrations of fluoxetine (1-10 micromol/l) caused significant shortening of action potential duration (APD) and depression of the plateau potential in guinea pig and rabbit papillary muscles and single canine ventricular myocytes. In rat papillary muscle, APD was not affected by fluoxetine (up to 100 micromol/l), however, the drug decreased the force of contraction with EC50 of 10 micromol/l. Fluoxetine (10 micromol/l) also decreased the maximum velocity of depolarization and action potential overshoot in each species studied. At this concentration no effect was observed on the resting membrane potential; high concentration (100 micromol/l), however, caused depolarization. In voltage clamped canine ventricular myocytes, fluoxetine caused concentration-dependent block of the peak Ca2+ current at 0 mV with EC50 of 5.4+/-0.94 micromol/l and Hill coefficient of 1.1+/-0.14 (n=6). In addition, 10 micromol/l fluoxetine shifted the midpoint of the steady-state inactivation curve of the Ca2+ current from -20.7+/-0.65 to -26.7+/-1 mV (P<0.001, n=8) without changing its slope factor. These effects of fluoxetine developed rapidly and were fully reversible. Fluoxetine did not alter voltage-dependence of activation or time constant for inactivation of I(Ca). Fluoxetine had no effect on the amplitude of K+ currents (I(K1) and I(to)). The inhibition of cardiac Ca2+ and Na+ channels by fluoxetine may explain most cardiac side effects observed occasionally with the drug. Our results suggest that fluoxetine may have antiarrhythmic (class I + IV type), as well as proarrhythmic properties (due to impairment of atrioventricular or intraventricular conduction and shortening of repolarization). Therefore, in depressed patients with cardiac disorders, ECG control may be suggested during fluoxetine therapy.

The role of platelet-activating factor (PAF) antagonists and nitric oxide in cardiac actions of PAF. Electrophysiological and morphological study.

Electrophysiological and ultrastructural effects of platelet-activating factor (PAF) antgonists, WEB 2086 and BN 52021 were compared in isolated guinea-pig hearts preparations. We studied the possible role of nitric oxide (NO) in electromechanical actions of PAF. Isometric twitches and intracellular action potentials (APs) were recorded from guinea-pig right ventricular papillary muscles and left atria. For electron microscopic study the hearts were perfused according to Langendorff technique. WEB 2086 (5 x 10(-9)-5 x 10(-7) M) significantly shortened the duration of atrial AP without changing the ventricular one, however, BN 52021 decreased both of them. The shortening of atrial and ventricular AP duration (APD) by both PAF antagonits were abolished by 4-aminopyridine (10(-3) M), a blocker of one type of K+ channels (IKto). Glibenclamide (10(-6) M) the blocker of ATP-dependent K channels prevented the shortening effect of BN 52021 (10(-6) M) on ventricular APD. Electron microscopic study of myocardial samples from hearts subjected to 30 min hypoxia/reoxygenation showed intracellular oedema, intramitochondrial swelling and fragmentation of mitochondrial christae, separation of intercalated disc. Pretreatment with WEB 2086 (5 x 10(-7) M) warded off nearly all damage caused by hypoxia/reoxygenation. Both WEB 2086 and NO synthase inhibitor NG-nitro-L-arginine methyl esther (L-NAME) (10(-3) M) abolished the negative inotropic effect of PAF (10(-7), 10(-6) M). L-NAME prevented the shortening of APD induced by 10(-7) M PAF. These results suggest that PAF may be responsible for myocardial ischemia and the beneficial effects of PAF antagonists in this pathological process could be due to their possible K+ channel stimulator property. These data support the possibility that NO contributes to the cardiac electromechanical alterations induced by PAF.

Cellular electrophysiological effects of platelet-activating factor (PAF) and its antagonist BN 52021 in cardiac preparations.

The effects of PAF and its antagonist BN 52021 were studied on the transmembrane action potential (AP) in atrial and ventricular papillary muscles of guinea-pig. PAF (10(-11)-10(-7) M) did not modify the resting membrane potential (RP) nor the maximum rate of depolarization (Vmax) either in atrial or in ventricular fibres. At 10(-11) M, PAF increased the amplitude of AP both in atrial and ventricular muscles. the repolarization phase was dose-dependently shortened in the case of atrium, while the duration of ventricular AP was somewhat increased. The K+ channel blocker 4-aminopyridine (10(-3) M) prevented the effect of PAF on the duration of atrial AP. BN 52021 (10(-7) M to 10(-5) M) produced a significant shortening of the duration of atrial AP and did not modify the other parameters. In papillary muscle up to 10(-6) M, it increased both RP and the amplitude of AP and caused a dose-dependent shortening of the repolarization. Neither PAF (10(-11) to 10(-7) M) nor BN 52021 (10(-5) M) was able to induce slow AP in guinea-pig atrial and ventricular preparations depolarized by 25 mM K+ Tyrode solution. PAF did not modify the slow AP elicited by isoprenaline (5 x 10(-7) M). The present findings suggest that neither PAF nor BN 52021 affects slow inward Ca2+ current but their effects on other ionic currents, e.g. K+ currents, may be important.

Cardiac ultrastructural effects of the platelet-activating factor and its antagonist BN 52021.

Platelet-activating factor-induced ultrastructural changes of myocardium were examined in isolated perfused guinea pig heart. The platelet-activating factor (10(-9)-10(7) M) caused the following electron microscopic changes: a) dilated capillaries filled with platelets and aggregated platelets. The endothelial cells adjoining the platelets remained uninjured but pericapillary oedema was observed. b) in the myocardium intracellular oedema, myofibrillar alterations, decrease of matrix density and rupture of crest in mitochondria can be seen. c) Ca2+ deposits in the cytoplasm increased and appeared in mitochondria, too. d) the intramitochondrially localised cytochromoxydase and succinic dehydrogenase activities were decreased. e) using lanthanum tracer permeability alterations were observed. Pretreatment with BN 52021 (10(6) M) completely prevented the morphological effects of the platelet-activating factor. From these results we conclude that the platelet-activating factor-induced vascular and ischemic like cellular damage appear to play an important role in the pathophysiology of myocardial ischemia.

Can the electrophysiological action of rosiglitazone explain its cardiac side effects?

Recent large clinical trials found an association between the antidiabetic drug rosiglitazone therapy and increased risk of cardiovascular adverse events. The aim of this report is to elucidate the cardiac electrophysiological properties of rosiglitazone (R) on isolated rat and murine ventricular papillary muscle cells and canine ventricular myocytes using conventional microelectrode, whole cell voltage clamp, and action potential (AP) voltage clamp techniques. In histidine-decarboxylase knockout mice as well as in their wild types R (1-30 µM) shortened AP duration at 90% level of repolarization (APD(90)) and increased the AP amplitude (APA) in a concentration-dependent manner. In rat ventricular papillary muscle cells R (1-30 µM) caused a significant reduction of APA and maximum velocity of depolarization (V(max)) which was accompanied by lengthening of APD(90). In single canine ventricular myocytes at concentrations ≥10 µM R decreased the amplitude of phase-1 repolarization, the plateau potential and reduced V(max). R suppressed several ion currents in a concentration-dependent manner under voltage clamp conditions. The EC(50) value for this inhibition was 25.2±2.7 µM for the transient outward K(+ ) current (I(to)), 72.3±9.3 µM for the rapid delayed rectifier K(+ ) current (I(Kr)), and 82.5±9.4 µM for the L-type Ca(2+ ) current (I(Ca)) with Hill coefficients close to unity. The inward rectifier K(+ ) current (I(K1)) was not affected by R up to concentrations of 100 µM. Suppression of I(to), I(Kr), and I(Ca) has been confirmed under action potential voltage clamp conditions as well. The observed alterations in the AP morphology and densities of ion currents may predict serious proarrhythmic risk in case of intoxication with R as a consequence of overdose or decreased elimination of the drug, particularly in patients having multiple cardiovascular risk factors, such as elderly diabetic patients.

Effects of rosiglitazone on the configuration of action potentials and ion currents in canine ventricular cells.

BACKGROUND AND PURPOSE: In spite of its widespread clinical application, there is little information on the cellular cardiac effects of the antidiabetic drug rosiglitazone in larger experimental animals. In the present study therefore concentration-dependent effects of rosiglitazone on action potential morphology and the underlying ion currents were studied in dog hearts. EXPERIMENTAL APPROACH: Standard microelectrode techniques, conventional whole cell patch clamp and action potential voltage clamp techniques were applied in enzymatically dispersed ventricular cells from dog hearts. KEY RESULTS: At concentrations ≥10 µM rosiglitazone decreased the amplitude of phase-1 repolarization, reduced the maximum velocity of depolarization and caused depression of the plateau potential. These effects developed rapidly and were readily reversible upon washout. Rosiglitazone suppressed several transmembrane ion currents, concentration-dependently, under conventional voltage clamp conditions and altered their kinetic properties. The EC(50) value for this inhibition was 25.2 ± 2.7 µM for the transient outward K(+) current (I(to)), 72.3 ± 9.3 µM for the rapid delayed rectifier K(+) current (I(Kr)) and 82.5 ± 9.4 µM for the L-type Ca(2+) current (I(Ca) ) with Hill coefficients close to unity. The inward rectifier K(+) current (I(K1)) was not affected by rosiglitazone up to concentrations of 100 µM. Suppression of I(to), I(Kr), and I(Ca) was confirmed also under action potential voltage clamp conditions. CONCLUSIONS AND IMPLICATIONS: Alterations in the densities and kinetic properties of ion currents may carry serious pro-arrhythmic risk in case of overdose with rosiglitazone, especially in patients having multiple cardiovascular risk factors, like elderly diabetic patients.

Headache-type adverse effects of NO donors: vasodilation and beyond.

Although nitrate therapy, used in the treatment of cardiovascular disorders, is frequently associated with side-effects, mainly headaches, the summaries of product characteristics of nitrate-containing medicines do not report detailed description of headaches and even do not highlight the possibility of nitrate-induced migraine. Two different types of nitrate-induced headaches have been described: (i) immediate headaches that develop within the first hour of the application, are mild or medium severity without characteristic symptoms for migraine, and ease spontaneously; and (ii) delayed, moderate or severe migraine-type headaches (occurring mainly in subjects with personal or family history of migraine), that develop 3-6 h after the intake of nitrates, with debilitating, long-lasting symptoms including nausea, vomiting, photo- and/or phono-phobia. These two types of headaches are remarkably different, not only in their timing and symptoms, but also in the persons who are at risk. Recent studies provide evidence that the two headache types are caused by different mechanisms: immediate headaches are connected to vasodilation caused by nitric oxide (NO) release, while migraines are triggered by other actions such as the release of calcitonin gene-related peptide or glutamate, or changes in ion channel function mediated by cyclic guanosine monophosphate or S-nitrosylation. Migraines usually need anti-attack medication, such as triptans, but these drugs are contraindicated in most medical conditions that are treated using nitrates. In conclusion, these data recommend the correction of summaries of nitrate product characteristics, and also suggest a need to develop new types of anti-migraine drugs, effective in migraine attacks, that could be used in patients with risk for angina pectoris.