Which Triptan Should I Choose?

This was the question in my mind as I faced a young man with a long history of migraines. He thought he had “tried them all” when I asked him what medications he had taken in the past for his migraines.

This patient had been experiencing migraines without aura and with moderate nausea for about 8 years. He had them once a month to every other month. At first, OTC ibuprofen worked. He then switched to Excedrin. More recently he had seen his primary care provider and had been given Fioricet, a combination of butalbital, acetaminophen, and caffeine. This drug did not help his headaches and made him feel “drunk.” Before I saw him in the neurology clinic, he had taken sumatriptan, 50 mg pills. He had taken one pill, about 4-5 hours after the onset of his migraine, and had not noted any benefit.

When I mentioned that there were other migraine-specific treatments-including other triptans-that he could try, he was surprised. Of the triptans, sumatriptan is typically prescribed for a few reasons. It has been around the longest (approved by the FDA in 1991); it is available as a generic; and it is typically covered by insurance. The pill dosages vary from 25 mg to 100 mg: I find 100 mg to be most effective.

I explained to my patient that when it comes to the acute treatment of migraines, treating at the earliest possible time with the most effective dose is best. I added that depending on migraine severity, any associated nausea, and how fast the migraine reaches maximum pain, alternative formulations of sumatriptan may be tried. I told him about an intranasal spray and injectable sumatriptan, which is one of the most effective migraine medications available.

I went on to discuss that sumatriptan is not the only “game in town.” There are a number of different triptans available (Table). This was welcome news for him as he did not “want to take the same medicine again.”

When he returned for follow up, he was doing well with zolmitriptan nasal spray.

Q: What are the options if this patient did not respond to the next choice -- or if he experienced adverse effects?

The answer is, it depends. The Table lists the triptans and their formulations that are currently available.

How do I choose among the triptans?   

Although the choice of triptan may initially be limited by the patient’s insurance coverage, a few guidelines can help in the selection process:

1. If one triptan does not work or causes side effects, try a different one. Each person responds differently to each of the triptans.

2.If the migraine is relatively severe, consider starting with injectable sumatriptan or intranasal zolmitriptan.

3. For those who get relief after a first dose but who tend to get migraine recurrences later in the day or the next day, consider eletriptan or frovatriptan. These agents are associated with lower migraine recurrence rates.

4. If there is significant nausea, consider the non-oral formulations of sumatriptan and zolmitriptan or the dissolvable tablet formulations of rizatriptan and zolmitriptan.

5. Don’t forget that adding an NSAID with the first of dose of triptan can make both medications more effective. This is why the FDA approved Treximet in 2008: this medication combines naproxen, 500 mg, and sumatriptan, 85 mg, in one tablet.

Are there other choices for treating an acute migraine?

. There is dihydroergotamine, which comes in injectable and intranasal spray formulations.

. There are oral ergotamine combinations.

. There is the more recent FDA approved transcranial magnetic stimulator (Spring TMS).

. You can combine anti-nausea medications, such as metoclopramide, and NSAID/analgesics.

I haven’t mentioned the oral opioids and oral barbiturate-containing analgesics since these can cause more long-term problems rather than benefits. But they are available in specific settings, such as in patients with heart disease.

And not to be dismissed: trigger avoidance is most effective for those patients who have lifestyle trigger components to their migraines.