Triptans for Migraine Treatment: Which One to Choose?

boy with migraine considering triptans

What are triptans?

Triptans are the most migraine-specific class of medications that are used to treat acute migraine attacks. In 1993, the first triptan Imitrex (sumatriptan) injection was made available for acute migraine treatment in the United States. Since then, it has revolutionized the treatment of migraines.  Most scientists agree that the discovery of sumatriptan is the most significant advance in the treatment of migraines in the past 50 years.

Soon after the introduction of the Imitrex injection on the market, an oral and a nasal spray form of this medication also became available. This was very important discovery because physicians tailored the delivery system of Imitrex to the type of migraine attack.

For example, if the patient has nausea or vomiting, a nonoral Imitrex product such as spray or injection make sense. If a patient has a mild headache attack without nausea or vomiting, the oral tablet is more convenient.

How do triptans work?

Triptans are not analgesic medications. They work by blocking the cascade of biochemical changes in the walls of the blood vessels that cause the headache and may also have an effect on the brain itself. These medications need to be taken as soon as the patient feels a migraine starting.

Are triptans really miracle drugs for migraines?

Before Imitrex, many patients used different nonspecific medications (e.g. aspirin, ibuprofen, diclofenac, acetaminophen, ergots etc.) for their migraine treatment. For many of them, these medications did not give them full relief and patients often overused them.  This caused unpleasant side effects such as abdominal pain, bleeding and ulcers, but also the rebound headaches when patients stopped using them.

It was also very common for migraine sufferers to take narcotic drugs and sedatives such as Vicodin (hydrocodone), Fiorinal (butalbital + aspirin + caffeine) or Fioricet (butalbital + acetaminophen + caffeine), which made the patients drowsy. They accepted they would be “down” for the rest of the day and would have to sleep or stay at home after taking these medications.

Hence why the introduction of triptans became a miracle for many of them. With triptans, most migraine sufferers can take the medication, be headache free in 2 hours, and return to full functioning.

How many different triptans are on the market?

Currently there are seven different triptans on the market:

  • Sumatriptan
  • Naratriptan
  • Almotriptan
  • Frovatriptan
  • Rizatriptan
  • Eletriptan and
  • Zolmitriptan

A novel triptan-analgesic combination tablet is also available. It is called Treximet (sumatriptan + naproxen sodium) and is probably the most migraine-targeted medication available for the acute treatment of migraines.

 

Which triptan to choose?

Sumatriptan: “The oldest one”

Sumatriptan was the first triptan introduced and proves to be very effective for migraines as demonstrated in various studies.  It’s most commonly known on the market as Imitrex, produced by GlaxoSmithKline (GSK). Imitrex comes in following forms:

  • Tablets of 25, 50 and 100 mg
  • Nasal spray of 20 mg and
  • Injection of 4 and 6 mg

Injection and nasal forms can be useful for migraine attacks associated with nausea and/or vomiting as well as for attacks that rapidly escalate.  The injection works within 10 minutes for most individuals, while nasal spray works within 15 minutes.

The injection form of Imitrex is considered by many headache specialists as the best medication to treat acute migraine headaches.  Imitrex injections can be also used for cluster headaches.

An injection of 4 or 6 mg may be given and then repeated after 1 hour for a maximum of 12 mg during a 24 hour period.  The nasal spray should only be given to adults, and no more than two times a day.  Imitrex’s oral version can be taken every 2 hours, but the maximal daily dose of 200 mg must not be exceeded.

Naratriptan: “A slow but long-acting one”

Naratriptan sells as Amerge and is also produced by GlaxoSmithKline.

It is only available in the tablet forms of 1 and 2.5 mg. A second dose of Amerge can be taken after 4 hours, but the maximal daily dose should not exceed 5 mg. Amerge is considered as a “long-acting” triptan. However, it may not start working as fast as the shorter acting triptans such as sumatriptan, zolmitriptan, rizatriptan and eletriptan.

It’s well studied in the prevention of menstrual migraines and shown to have fewer side effects compared to other triptans.

Almotriptan: “The best-tolerated one”

Almotriptan goes by the brand name Axert, produced by Janssen Pharmaceuticals, Inc. It is the first triptan to be FDA approved for use among the adult population.

It comes in a 6.25 and 12.5 mg tablet and can be repeated after 2 hours, with the maximal daily dose of 25 mg. Although it is a short-acting triptan with fast onset ad probably the best-tolerated triptan, for some patients it’s not sufficient.

Some studies found it less effective than sumatriptan, zolimitriptan, rizatriptan and eletriptan, but individual experience varies.  In one study, Axert had a favorable side effect profile (less chest pain in patients) compared with sumatriptan.

Frovatriptan: “The longest-acting one”

Frovatriptan sells on the market as Frova, manufactured by Endo Pharmaceuticals Inc.

It is available in the tablet form only in one dose of 2.5 mg. A second dose can be taken after 2 hours, as can the third dose.  A daily dose of 7.5 mg should not be exceeded. Frovatriptan is considered the longest acting of all triptans.  Generally, its effects last for 26 hours. This is a fantastic advantage for those with long-lasting and debilitating migraine attacks. Frova is well tolerated among most individuals.

Eletriptan: “A short-acting one”

Eletriptan goes by the brand name Relpax, produced by Pfizer Inc.

It is available as a 40 mg tablet, and can be repeated after 2 hours to maximal daily dose of 80 mg. It is a short-acting triptan.

Rizatriptan: “The one with a mint flavor melting on the tongue”

Rizatriptan identifies on the market as Maxalt, manufactured by Merck.

It is available in a tablet form of 5 and 10 mg. However, these tablets come in two forms:

  • Maxalt – standard tablets swallowed with water
  • Maxalt MLT – rapidly dissolving tablets that melt on the tongue when taken. They have a mint-like flavour when dissolved.

Maxalt is a short-acting triptan, which can be repeated after 2 hours and then again in another 2 hours. The maximum daily dose is 30 mg.

Recently, Maxalt got FDA approval for use in pediatric patients with migraine attacks.

Zolmitriptan: “The one with an orange flavor”

Zolmitriptan sells under the brand name Zomig, manufactured by Impax Laboratories, LLC.   It is available in the following forms and doses:

  • Oral tablets of 2.5 and 5 mg. Oral tablets can be repeated after 2 hours, but the maximal daily dose of 10 mg should not be exceeded
  • Rapidly dissolving tablets: This form is sold under brand name Zomig ZMT and is orange-flavored. Like Maxalt MLT, Zomig ZMT offer the advantage of not needing water to take but does not offer quicker onset of action than oral tablet
  • Nasal spray: 5 mg. Similarly as Imitrex nasal spray, Zomig nasal spray offers fast onset of action within 15 minutes. The most common side effect of this product is a bad taste in your mouth.

Which triptan is the best?

The short answer is we’re not sure.  No triptan is best for all.  Rather, the best triptan is the one that works for the particular patient and his/her specific migraine attack.  Some patients prefer Imirex, while other like Frova or Relpax.

Therefore, if you’re considering triptans for the acute treatment of migraines, the following criteria should be met:

  • Headache free and back to full function in 2 hours
  • No need to repeat the dose soon after
  • No need to add another medication
  • Headache does not come back after 24 hours
  • The medication is safe and well-tolerated.

 

 If not, we do not recommend continuing with use of triptans.

 

 

 

 

 

 

 

 

 

 

 

References:

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