Use of triptans in the attack therapy of migraine

Although extensive studies have been conducted to identify the advantages and disadvantages of each substance, for practical purposes it is sufficient to divide triptans into 3 groups:

Group 1: very fast and very strong effect, but short duration of action and higher potential for side effects

  • Sumatriptan 6 mg sc (Imigran Inject)
  • Sumatriptan-Hormosan Inject 6 mg sc.
  • Sumatriptan MigraPen Inject 3 mg sc.

 

Group 2: balanced efficacy profile between effectiveness and tolerability, as well as speed and duration of action

  • Almotriptan 12.5 mg tablets (Almogran, available without a prescription as Dolortriptan)
  • Eletriptan 40 mg tablets (Relpax)
  • Rizatriptan 10 mg tablets/ 10 mg orodispersible tablet (Maxalt)
  • Sumatriptan 100 mg tablets (available over the counter in pharmacies in a 50 mg dosage) / 20 mg nasal spray (Imigran) 
  • Zolmitriptan 5 mg tablets/ 5 mg nasal spray (AscoTop)

The lower-dose formulations not listed, i.e., Eletriptan 20 mg tablets, Rizatriptan 5 mg tablets/orodispersible tablet, Sumatriptan 50 mg tablets, Sumatriptan 10 mg nasal spray and Zolmitriptan 2.5 mg tablets/orodispersible tablet, tend to be less effective with fewer side effects than the higher dose.

 

Group 3: sustained effect and very good tolerability, low rate of headache recurrence, but rather slower onset of action

  • Frovatriptan 2.5 mg tablets (Allegro)
  • Naratriptan 2.5 mg tablets (Naramig, available without a prescription as Formigran)

The success of treatment with triptans can be optimized if the following points are observed:

  • Triptans can also be effective in advanced stages of migraine attacks, but as with any medication, the earlier they are taken during a migraine attack, the more complete and lasting the treatment success will be. However, they should only be taken after any aura has subsided and the headache phase has begun.
  • If a triptan is ineffective during a migraine attack, repeating the dose during the same attack is generally also ineffective, provided the initial dose was the maximum recommended single dose (e.g., sumatriptan 100 mg orally or sumatriptan 6 mg subcutaneously). However, if the patient starts with a low dose, such as sumatriptan 50 mg orally or eletriptan 20 mg orally, repeating the dose after approximately two hours may still provide relief. For subsequent attacks, however, it is advisable to choose a higher initial dose.
  • If a triptan is ineffective even after repeated use, this does not necessarily mean that triptans are generally ineffective for that patient. In this case, a triptan from a more potent group should be chosen. A trial of sumatriptan will ultimately provide definitive information about the individual effectiveness of triptans.
  • Triptans are very safe, provided that the contraindications – especially any circulatory disorders – are observed.
  • Triptans should not be used during pregnancy due to insufficient data on their safety. If breastfeeding, a 24-hour break from breastfeeding is required after taking a triptan.
  • If recurrent headaches occur, the next dose of a triptan is usually just as effective as the previous one. However, it should not be taken more than twice in 24 hours. If patients regularly report recurrent headaches, a long-acting triptan such as naratriptan or frovatriptan should be tried first. Alternatively, the combination of triptans with a long-acting nonsteroidal anti-inflammatory drug (NSAID) such as naproxen has also proven effective in these cases.
  • Combining a triptan with an antiemetic is possible to improve absorption.
  • Acute headache medication, including triptans, should not be used more frequently than 10 days per month to prevent a higher frequency of migraine attacks and, ultimately, the development of medication overuse headache (MOH). For patients with frequent attacks, this may mean having to endure some migraine attacks untreated. However, experience shows that after an untreated attack, the pain-free interval is often significantly longer than after a (successfully) treated attack.
  • Triptans were initially only approved for use in individuals aged 18 and over. However, controlled studies have shown that sumatriptan 10 mg nasal spray and AscoTop 5 mg nasal spray, in particular, are reliably effective and well-tolerated, so these formulations can now officially be used from the age of 12.

The correct use of triptans and pain medication

As you now know, the frequent use of medications (triptans, painkillers) can itself trigger a headache and worsens the problem of primary headache types such as migraine and tension headache.

Therefore, adhere to the "rule of 10," which states that pain should only be treated on 10 days per month. On 20 days, no triptans or pain medication should be taken to avoid the risk of medication overuse headache (MOH).

If pain occurs on more than 10 days per month, behavioral therapy measures should be implemented more consistently. Likewise, preventative medication should be considered, or an existing medication should be optimized.

If status migrainosus (more than 3 consecutive days of migraine) persists, it can be treated with a few days of cortisone. However, this measure should only be taken every few months and always in consultation with the treating physician.

Now a word about the correct behavior during an attack. The effective triptan helps you to continue your planned daily routine despite the attack. However, it's important to remember that the attack continues in the background. If you don't withdraw during the attack and simply carry on, your brain still has to process the stimuli that were already overwhelming. This is precisely what triggered the attack in the first place. This puts further strain on the already overtaxed nervous system. It's surely clear to everyone that this cycle is unhealthy, worsens the pain condition, and can even lead to it becoming chronic. Therefore, it would be highly recommended to give your nervous system the necessary rest it actually needs during an attack. It's clear that this is often not feasible in professional life, but sometimes it would be possible, yet we continue to run on the hamster wheel.