Finding the Triptan that Fits

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The patient seeing me for treatment of her migraines was flustered. She had had migraines for more than 10 years. She would get a migraine once or sometimes twice a month. These were rarely related to her menstrual cycle. After trying the over-the-counter pain relievers ibuprofen and Excedrin with relief for a few years, she had reached the point where it took 3 to 4 of either of these pills to “take the edge off” the migraine and she sought alternative treatment with her primary care provider.

At first she was given Fioricet, a combination of butalbital, acetaminophen, and caffeine, to try. This combination made her “tired” and “wired” and “drunk” all at once. It might have helped the headache mildly but not very much. She did not like the way she felt on this medication and stopped it. She was then given sumatriptan to try. She took one dose and felt it did “nothing.” She returned her primary care provider at which point she was referred to Neurology

This situation is typical. Patients are tried on one or two acute treatments for migraine without clear benefit and are then sent to Neurology.

After a review of her migraine history, she made it clear she wanted something to take only when needed for a migraine. She had no interest in daily preventive medications. I agreed, given the infrequent nature of her migraines. Reviewing her prior medication trials, I found out that the dose of the sumatriptan she had tried was the 50 mg pill and that she had taken this almost 8 hours after she could tell her headache was a migraine. Since her insurance allows only 9 pills per prescription, she decided to “save it for when she knew she really had a migraine.” I explained why I thought she had not really given this medication a good trial.

One of the tenets of headache medicine, when it comes to acute treatment, is to treat early and to give an effective dose. My experience has led to me to believe that sumatriptan, although available in 50 mg doses, is more effective at the dose of 100 mg. Pooled data from numerous studies support this view.¹ This meant she had the option of a retrial of higher dose sumatriptan or a trial of one of the other six triptan medications available.

I am at times surprised by the relative lack of awareness of the other triptans that are available for migraine patients. Now that medication samples are few and far between, I occasionally will come across patients who are aware of Relpax (eletriptan) or Maxalt (rizatriptan). It is less likely that patients will have heard of the remaining four triptans: Zomig (zolmitriptan), Amerge (naratriptan), Frova (frovatriptan) and Axert (almotriptan).

The importance here is that with the exception of naratriptan and frovatriptan, the other four triptans are considered equally efficacious in migraine treatment. Lack of efficacy for one of these medications should not automatically eliminate the others to try.²

Naratriptan and frovatriptan are in a category by themselves, typically because of their delayed onset of action and lower likelihood of side effects, but also because of the absence of migraine recurrence seen with these 2 formulations, which is attributed to their longer duration.³ I tend to use these 2 agents in patients whose migraines are slower to reach peak intensity or patients who are “sensitive” to medication side effects. Their benefit has been demonstrated in treating menstrual migraine where they have been used in a short course of “prophylaxis” for this type of headache.⁴

The patient wanted to try a different medication. She tried the nasal spray zolmitriptan and now has good control of breakthrough migraines.

References:

1. Winner P, Landy S, Richardson M, Ames M. Early intervention in migraine with sumatriptan tablets 50 mg versus 100 mg. Clin Ther. 2005;27:1785-1794.

2. Dahlöf CGH. Infrequent or non-response to oral sumatriptan does not predict response to other triptans-review of four trials. Cephalalgia. 2006;26:98-106.

3. Pascual J, Mateos V, Roig C, Sanchez-Del-Rio M, Jiménez D. Marketed oral triptans in the acute treatment of migraine. Headache. 2007;47:1152-1168.

4. Sullivan E1, Bushnell C. Management of menstrual migraine. Curr Pain Headache Rep. 2010;14:376-384.