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Which Triptan Is Best for Migraine?

As someone with a long, lamentable relationship with migraines, I can say with certainty that I have been ‘around the block’ with different migraine drugs. One such group of treatments, now considered a first line treatment for migraines, is the class of medications called the triptans.

The triptans have a long history dating back to the 1950’s, when scientists discovered that medications resembling serotonin could reduce the severity of migraine attacks. However, these original drugs, including IV serotonin itself, had too many side effects to be widely used. During the following decades, scientists were able to isolate the specific serotonin receptor responsible for ending migraine attacks and created a new class of medication – called a triptan - to activate this receptor. They found that triptans also constrict the enlarged blood vessels in the brain that push on painful nerves, further reducing pain. This first triptan was created in the 1990s, and this was considered a medical breakthrough – providing relief for millions of migraine sufferers.

In this article, we’ll break down the differences between the triptans that have since been developed.

I’m new to migraines – and I don’t know where to start!

If you are new to migraines, or new to taking medications for migraines, your doctor will likely start you on a medication called sumatriptan (Imitrex®). This is the oldest and most widely used triptan. For the medication to have the greatest effect, you should take it as soon as you have symptoms – the longer you wait the less effective the medication will be. You will likely feel relief in about half an hour, but it may take up to two hours. Additionally, the sooner you take it, the less likely that the migraine will come back.

Once you feel the relief of a triptan, it can be tempting to always take it at the first sign of a headache. Unfortunately, doctors recommend limiting the use of triptans to at most twice a week. This is because taking a triptan too often can actually cause more headaches (called ‘medication overuse headaches’). When possible, you should always try to prevent a migraine by eliminating or reducing potential triggers such as skipping meals, poor sleep, alcohol, or certain food such as chocolate or MSG.

When I have migraines, I get so nauseous that I can’t hold down any food!

Luckily, many different formulations of triptans have come onto the market that eliminate the need for taking the medication by mouth. If you are currently on sumatriptan, you can ask your doctor about switching to a nasal spray or an injectable formulation. The injectable formulation comes as an autoinjector, making administration easy. The needle is very small and will not pierce past your inner layer of skin. It’s worth noting that both medications (the intranasal and injectable form of sumatriptan) work a lot faster and are more effective than the oral formulation, but also come with significantly more side effects. Many people describe the nasal spray as having an unpleasant aftertaste. Additionally, the nasal spray and the auto-injector can be considerably expensive.

Zolmitriptan (Zomig®) also comes as a nasal spray formulation and is faster acting than the oral tablet. The nasal spray also causes an aftertaste, which can be worse than sumatriptan’s. Doctors are more likely to prescribe sumatriptan first as zolmitriptan is known to cause more odd sensations, called ‘triptan sensations.’ These sensations may cause tightness, pressure, or neck and jaw pain.

I’ve tried a triptan, but it didn’t work, or it gave me too many side effects.

Everyone is different and it’s expected that medications work differently for each of us. If your migraine wasn’t relieved by several trials, then your doctor may increase the dose, change to a different triptan, or switch to a different dosage form. During a migraine attack, some people experience a slowing of digestion. Therefore, oral medications may not be absorbed. Switching to a nasal or an injectable form may help. Additionally, some people find that taking an NSAID (such as Aleve®) with the triptan may increase how well it works. You can also request a special mixture of sumatriptan and naproxen (Treximet®) for convenience.

If you are finding that your current triptan is giving you too many side effects, you may want to switch to a longer acting triptan. These longer acting triptans include naratriptan (Amerage®) and frovatriptan (Frova®) and are known for having fewer side effects. You should know that because these triptans are longer acting they are also slightly less effective at treating migraines. However, longer acting triptans may also reduce the chance that your headache will come back.

Lastly, if you have migraines that come on rapidly before medications have a chance to work you may want to consider changing to a triptan that will be rapid acting. Examples of these are the zolmitriptan nasal spray and the injectable or nasal spray version of sumatriptan.

You should always talk to your doctor about what other medications you are taking, as some triptans may require dose adjustments with other drugs. Tell your doctor if you have a history of heart attack or stroke, as these medications may increase your likelihood for these events.

Overall, whether you are new to migraines or a seasoned veteran, there is plenty of wiggle room and variation between the triptan medications. Below, we’ve provided a summary of the differences between each of the triptan medications so you can pick which may be best for you.

 

Common Triptans for Migraine

Sumatriptan (Imitrex®)

Tablet, injectable, nasal spray

·       Original triptan

·       Treximet® is formulated with naproxen (Aleve®)

·       Injectable and nasal spray have faster onset; more side effects

Almotriptan (Axert®)

Tablet

·       Short acting

Frovatriptan (Frova®)

Tablet

·       Longer acting; Slower onset

Eletriptan (Relpax®)

Tablet

·       Short acting

·       More fatigue and nausea

Naratriptan (Amerge®)

Tablet

·       Longer acting; slower onset

·       Less side effects overall

·       Preferred for recurrent headaches

Rizatriptan (Maxalt®)

Tablet, ODT

·       Possibly most effective triptan

·       Higher incidence of neurologic side effects (pressure, fatigue, dizziness)

Zolmitriptan (ZOMIG)

Tablet, ODT, nasal spray

·       Higher incidence of dry mouth, fatigue, neck & jaw pain

·       Short acting

·       Nasal spray has aftertaste

  

 

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