Use of triptans in the treatment of migraine attacks

Even though many efforts have been made in extensive studies to identify the advantages and disadvantages of the individual substances, in practice it is sufficient to divide the triptans into 3 groups:

Group 1: very quick 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 effect profile between effect and tolerability as well as speed of action and duration of action

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

The dosage forms with lower doses not listed, ie Eletriptan 20 mg tablet, Rizatriptan 5 mg tablet/orodispersible tablet, Sumatriptan 50 mg tablet, Sumatriptan 10 mg nasal and Zolmitriptan 2.5 mg tablet/orodispersible tablet, each tend to be less effective at less Side effects than the higher dose.


Group 3: lasting effect and very good tolerability, low rate of recurring headaches, but rather slower onset of action

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

The success of treatment when using triptans can be optimized if the following points are taken into account:

  • Triptans can also be effective for advanced migraine attacks, but the same applies to triptans: the earlier in the migraine attack they are taken, the more complete and lasting the treatment success will be. However, it should only be taken after any aura has subsided with the beginning of the headache phase.
  • If a triptan does not work in a migraine attack, repeating the triptan in the same attack is usually also not effective, provided that the starting dose was also the recommended maximum dose of the single dose (e.g. sumatriptan 100 mg orally or sumatriptan 6 mg sc). However, if the patient starts with a low dose, e.g. Sumatriptan 50 mg orally or Eletriptan 20 mg orally, repeating the dose after about 2 hours in the office can still provide relief. In subsequent attacks, however, it is recommended to primarily choose a higher starting dose.
  • If a triptan is not effective even after repeated use, this does not mean that triptans are fundamentally ineffective for a patient. In this case, a triptan should be chosen from a group with higher effectiveness (see above). A therapeutic trial with sumatriptan sc finally provides definitive information about the individual effectiveness of triptans
  • The safety of triptans is very good as long as the contraindications - in particular any circulatory disorders - are taken into account.
  • Triptans should not be used during pregnancy due to insufficient safety data. If you are breastfeeding, you must stop breastfeeding for 24 hours after taking a triptan.
  • If a recurring headache occurs, a next dose of a triptan is usually just as effective as the previous one. However, it should not be taken more often than twice in 24 hours. If patients regularly report recurring headaches, a long-acting triptan such as Naratriptan or Frovatriptan should first be tried. Alternatively, the combination of triptans with a long-acting non-steroidal anti-inflammatory drug such as naproxen has proven effective in these cases.
  • Combining a triptan with an antiemetic is possible to improve absorption.
  • Acute headache medication and therefore also triptans should not be used more frequently than 10 days per month in order to prevent an increase in migraine attacks and ultimately the development of MÜK (medication overuse headache). For patients with frequent attacks, this means that they may have to endure untreated migraine attacks. However, practice shows that after an untreated attack, the symptom-free interval is often significantly longer than after a (successfully) treated attack.
  • Triptans were initially only approved for people over the age of 18. However, controlled studies have shown that Sumatriptan 10 mg nasal and AscoTop 5 mg nasal in particular are reliably effective and well tolerated, so that these dosage forms can now officially be used from the age of 12.

How to use triptans and pain medications correctly

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

Therefore, follow the rule of 10, which states that pain should only be treated on 10 days a month. No triptans or pain medications should be taken for 20 days to avoid the risk of MÜK (medication overuse headache).

If there are more than 10 days of pain per month, behavioral therapy measures should be used more consistently. Medicinal prophylaxis should also be considered or an existing one should be optimized.

If there is status migraenosus (more than 3 migraine days in a row), this can be stopped with a few days of cortisone. However, this measure should only be taken every few months and always in consultation with the treating doctor.

Now a word about correct behavior during an attack. The well-acting triptan helps you to continue with your planned daily routine despite the attack. But you always have to keep in mind that the attack continues in the background. If you don't withdraw during the attack and just carry on, the brain still has to process the stimuli that were already too much. This is precisely why the attack was triggered. This puts further strain on the already overstressed nervous system. It is certainly clear to everyone that this circulation is not healthy, that it worsens the pain and can cause it to become chronic. It would therefore be highly recommended to give the nervous system the rest it actually needs during the attack. It is clear that this often cannot be achieved in professional life, but sometimes it would be possible, but the rat race continues.