Determining the correct time to take triptans
The triptan threshold

Triptans: drug of choice

The substance has been there since 1993

  • Sumatriptan

as the first so-called selective serotonin agonist available in migraine therapy. Today the following other active ingredients from this substance class are available:

  • Naratriptan
  • Zolmitriptan
  • Eletriptan
  • Almotriptan
  • Rizatriptan
  • Frovatriptan

Since triptans not only combat migraine headaches, but also counteract accompanying symptoms such as nausea, vomiting, sensitivity to noise and light, additional use of an anti-nausea and vomiting medication (antiemetic) is sometimes not necessary. In severe attacks, however, the mobility of the muscles in the stomach is so impaired that the triptan cannot be transported further into the intestines. In this case, it is still recommended to administer an antiemetic (metoclopramide, domperidone) about 15 minutes before taking the triptan.

A crucial effect of triptans: They block the release of nerve messengers (neuropeptides and neurotransmitters), which can trigger local neurogenic inflammation in the blood vessels of the brain. In addition, triptans can normalize the increased nerve activity in various brain centers during the migraine attack and narrow enlarged short circuits between the arteries and veins of the brain (anastomoses), thereby normalizing the oxygen supply to the brain.

While pain medications work everywhere in the body, triptans essentially bind specifically and selectively to the switching points (5-HT1B and 1D receptors), which are located in exactly the parts of the brain where the migraine disease processes take place.

Important rules for all triptans

  • Triptans should only be used after a preliminary medical examination including blood pressure measurement and electrocardiogram as well as individual advice. This also and especially applies to first-time use in an emergency situation in the event of severe migraine attacks.
  • They should not be used if there is a persistent headache due to medication overuse, or if there are contraindications, such as a condition after a heart attack, stroke, other vascular diseases, high blood pressure, liver or kidney diseases.
  • Do not take triptans until the headache phase begins, but then as early as possible. These active ingredients should not be administered during the aura phase. The reason for this is that they are unable to directly influence the symptoms of the aura. They also may not effectively improve migraine symptoms if given too early before the headache phase. In addition, a narrowing of certain brain vessels is believed to be a possible cause during the aura phase. Vasoconstrictive agents such as triptans can therefore lead to an increase in symptoms during this phase.
  • Under no circumstances should triptans be administered in conjunction with ergotamines. Since both ergotamines and triptans lead to vasoconstriction, overlapping the two active ingredients can result in a dangerous addition of the vasoconstrictive effect. However, since ergotamines are already a thing of the past in migraine therapy, this problem is unlikely to occur again. This could only apply to patients with cluster headaches who, in exceptional cases, may use ergotamines.
  • Since the triptans have a limited time of action, migraine symptoms recur in around 30 percent of the treated patients after the time of action has worn off. However, this so-called recurring headache can be successfully treated with a new dose. Important: This does not mean that the migraine attack is postponed or prolonged! The rule of thumb is that the dose can be repeated once a day. If you take the medication more than twice in one day, you will need to work with your doctor to develop a new therapy concept that will lead to better effectiveness. It is then recommended to choose a long-acting triptan, such as Almotriptan, Naratriptan or Frovatriptan. The combination with a long-acting so-called COX-2 inhibitor (e.g. Arcoxia 120 mg) or an NSAID (e.g. Naproxen 500 mg) can also reduce the likelihood of recurring headaches.
  • Regardless of the dose, you should definitely ensure that you do not take the medication for more than 10 days per month, otherwise there is a risk of constant headaches due to overuse of medication.
  • Patients with a high frequency of attacks are often unsure whether they should take the triptan when the headache begins. You are then conflicted between, on the one hand, taking the medication very early in the attack and, on the other hand, being careful with the upper limit of taking it on 10 days per month. For this reason, a checklist, the so-called “triptan threshold” (see download box at the top right), was developed, which can be used to determine the exact time of intake individually.
  • The manufacturer recommends that triptans only be administered up to age 65. In consultation with the treating doctor and after a cardiological examination, there is nothing to speak against the use of triptans even beyond this age. There are now also studies on the use of sumatriptan and zolmitriptan as a spray in adolescents between the ages of 12 and 18. These showed no increased risk in this age group. However, triptans should not be administered to children under the age limit of 12 years.
  • Typical side effects of triptans are a slight, general feeling of weakness and undirected dizziness, abnormal sensations, tingling, a feeling of warmth or heat and mild nausea. Very rarely, a feeling of tightness in the chest and neck area can also occur. As a rule, the side effects are mild and go away on their own.