June 13, 2022

Article at Migraine Again

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Triptans to Relieve Migraine Attacks: Safety, Options, and More

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While migraine attacks are likely as old as civilization itself, the first effective, migraine-specific treatment — the triptans — did not become available until the 1990s. Since their development, the triptans have reigned as the most common class of drug used to stop a migraine. Because migraines are disabling and can last days, a drug that can abort a migraine is an important tool that can make a huge difference in the lives of millions of people.

Are You a Good Candidate for Triptans?

Triptans are for the acute treatment of migraine, meaning you take one when you feel a migraine attack coming on.

“Migraine treatments are divided into two categories: “acute” treatments, which are used to treat attacks when they occur, and “preventive” treatments, which are used daily or periodically to try to reduce the frequency of attacks and to manage the underlying disease process,” explains Andrew Charles, MD, director of the UCLA Goldberg Migraine Program and a professor of neurology at UCLA’s David Geffen School of Medicine.

If you haven't already tried them, the American Academy of Neurology recommends that you try a nonprescription medication first to treat mild to moderate acute migraine attacks. A triptan can be considered if your migraines are moderate to severe or if the over-the-counter meds don't work. Over-the-counter pain relievers like acetaminophen, ibuprofen, naproxen, and aspirin are convenient and inexpensive options, as long as they provide pain relief and adequately treat migraine attacks.

Most people with migraines find that over-the-counter pills just don't cut it. Triptan medications for migraine relief are a great option for people who find their symptoms too severe for over-the-counter treatment. If your severe migraines disrupt your normal life, chances are that triptans are your best option for relief.

It's a good idea to take a triptan at the first sign of a migraine attack to get the best results. Along with the pain, triptans can also relieve other migraine symptoms like nausea, vomiting, and sensitivity to light and noise.

A 2015 meta-analysis found that 42 to 76% of people found headache relief from a standard dose of triptans, and 18 to 50% of people experienced freedom from pain two hours after taking triptans.

For many people who get migraines, triptans are a lifesaver.

Are Triptans Safe? Who Should Not Use Triptans?

Although triptan medications have been studied and used widely for decades, they are not right for everyone. Triptans should not be used by people with cardiovascular disease or poorly controlled hypertension, according to Richard Lipton, MD, director of the Montefiore Headache Center in the Bronx, New York, and Stewart Tepper, MD, professor of neurology at the Dartmouth Geisel School of Medicine in Hanover, New Hampshire. Triptans can cause stroke or arrhythmia in predisposed individuals. Women over 55 and men over 40 should take with caution.

Triptans are generally avoided in pregnancy, although there is a fair amount of data that shows good safety with sumatriptan in pregnancy. If you're pregnant, talk with your physician about medication options but also about some of the natural treatments available, such as ginger, acupuncture, and menthol. Neuromodulation may also be an option for you. Again, ask your doctor.

Triptans for Migraine With Aura

If you are among the 30% of people who experience migraine aura with their migraines — disturbance of the senses that occur before the pain begins — you may also find migraine relief with triptans. Knowing the best time to take triptans for migraine relief, however, is trickier if you get migraine aura.

Researchers aren't exactly sure if taking a triptan before, during, or after aura symptoms begin is the best way to get relief, so they recommend you experiment with timing. Try taking a triptan during, before, and then after the aura in three different attacks. Take note of any difference in speed and efficacy based on timing.

While triptan medications are safe to use for most migraine attacks with aura, there are, however, two forms of migraine with aura that are unsafe to treat with triptans. Basilar migraines begin in the brainstem and can cause imbalance, double vision, and even a lowered level of consciousness. Hemiplegic migraines involve weakness on one side of the body and can often mimic a stroke. If you experience either basilar or hemiplegic migraine attacks, talk to your doctor about your best options for relief, since triptans are most likely not safe to use.

Are Triptans Safe for Children?

Sadly, migraine attacks occur in 8 to 23% of children and adolescents, according to a 2010 study on treating pediatric migraines. Published in the journal Pediatric Drugs, this large study looked at different triptans and evaluated their efficacy in young people. Both over-the-counter NSAIDs and certain triptans are safe to use for children and adolescents.

Nasal sumatriptan, oral rizatriptan, nasal zolmitriptan, and oral almotriptan are the most effective meds for stopping a pediatric migraine. These forms are a great place to start if your child or teenager is looking for their perfect migraine medication, but other forms are also safe for kids. Triptans for migraine relief are an important tool for many children and teenagers who find themselves missing school frequently thanks to migraines.

Is It Safe to Take Triptans Daily? Can Triptans Make Migraines Worse?

While triptan medications may be safe for you in general, using them frequently for the acute treatment of migraine can be complicated. Let’s look at the pluses and minuses of using triptans to treat migraine.

On the plus side, having an effective way to stop a migraine helps give back some of the peace of mind that migraines demand. According to Dr. Lipton, effective options for the treatment of migraine are also essential because they can help keep migraines episodic and infrequent. Some people with migraines experience chronic migraine — headaches on 15 or more days a month. Most people with chronic migraine started with infrequent episodic migraine that progressed.

A person whose migraine attacks are nonresponsive to acute treatment such as triptans is more likely to see their migraines progress to chronic migraine. People with chronic migraine, however, can also find relief with triptans.

On the minus side, triptans for migraine relief should be used no more than nine days per month to avoid rebound headache, also called medication overuse headache. If you find yourself taking triptans more than that, or you want to take them more often, talk to your doctor about using preventive medications or other treatments to reduce the number and severity of your attacks.

Overall, triptans give millions of people a degree of control over their pain. The unpredictability of attacks gives migraine a kind of terrible power over lives. Any tool that provides relief, especially an as-needed or acute tool, like the triptans, is an important option for those looking for a migraine treatment that provides full pain relief.

What Kinds of Triptans Are Available?

There are a variety of triptans for migraine relief on the market and a variety of ways to administer them, including regular oral tablets, auto-injectors, tablets that dissolve in the mouth, and nasal sprays. If you experience a great deal of nausea or vomiting with your migraines, you may prefer a non-oral way to get the triptan in your system, like an injection or nasal spray.

Since different migraine attacks come with different symptoms, it is a good idea to have a variety of medication options on hand, if they are available.

Details and availability vary by country, but in the United States there are several triptans available. Many are available in less-expensive generic formulas, but some, especially those with unique delivery systems, are available only in more expensive brand name formulations:

  • Sumatriptan (Imitrex): The first triptan approved for use in migraine. Available in oral tablets, nasal spray, and auto-injector. The injectable form has the fastest onset of action for severe migraine attacks.
  • Rizatriptan (Maxalt): Available in oral tablets and oral dissolving tablets. It has the fastest onset of action for oral triptans but also has the highest rate of recurrence after usage. Rizatriptan may be a good option if your attacks come on fast but don’t last long.
  • Almotriptan (Axert): Available in oral tablets. This is the only triptan with a U.S. Food and Drug Administration indication specifically for adolescent patients, though others have been prescribed safely.
  • Naratriptan (Amerge): Available in oral tablets. It has a slower onset of action but a longer half-life than sumatriptan. Naratriptan may be a good option for patients who have attacks of longer duration.
  • Zolmitriptan (Zomig): Available in oral tablets, oral dissolving tablets, and nasal spray. It has a slower onset of action but a longer half-life. Zolmitriptan may be a good option for patients who have attacks of longer duration. The dissolving tablets and nasal spray may help patients experiencing nausea/vomiting.
  • Frovatriptan (Frova): Available in oral tablets. Like several others on the list, Frovatriptan has a longer half-life than sumatriptan, making it another good candidate for patients whose attacks last longer.
  • Eletriptan (Relpax): Available in oral tablets. It has a slower onset of action and longer half-life than sumatriptan but also has a high rate of side effects. Eletriptan may be a good option for patients with severe attacks of long duration.
  • Onzentra brand sumatriptan nasal powder: This option is not available in generic form. Patients use a special nasal delivery device that helps them blow the powered sumatriptan high into the nasal passages, where tissue rich in blood vessels can absorb the medication. Onzentra may be a good option for patients who need fast relief but experience significant nausea/vomiting.

What are the risks of triptans? Do triptans cause brain damage?

Although there is no evidence that triptans cause brain damage, they do carry risks that are not appropriate for everyone. Triptans may not be for you if you have cardiovascular disease and/or high blood pressure, if you are pregnant, if you get basilar migraine attacks or hemiplegic migraine attacks, or if you are at increased risk of stroke. Men over 40 and women over 55 may face additional risk and should use triptans with caution.

Triptans don’t mix well with certain other medications, like MAO inhibitors or ergot alkaloids. Talk to your doctor about all the other medications you take, even if you take them only occasionally, to make sure there are no dangerous interactions.

What Are My Options if Triptans Don’t Work for Me?

First, if you tried a single kind of triptan but didn’t get relief, consider trying another kind. Many people with migraine disease try several kinds of triptans before they find the one that works best for them.

Next, consider whether a different form of triptan might be right for you. People who get nausea and vomiting with their attacks may not get the best results from oral tablet forms, says Dr. Charles.

If [vomiting occurs] soon after you've taken the medication, then you may vomit the medication before it's absorbed. More importantly, though, is the fact that you're nauseated means that the absorption of the medication through your gastrointestinal tract may be impaired even without vomiting. You may not absorb an effective dose of a medication if you're nauseated.

If this sounds like you, a triptan in a nasal spray or injection form might give you better results.

What About New Treatments?

Next, if triptans don’t work for you or you’re not a good candidate for them, there are new options for the acute treatment of migraine. Gepants are calcitonin gene-related peptide (CGRP) antagonists developed as acute treatments to take when you have an attack, like triptans. Rimegepant (brand name Nurtec ODT) and ubrogepant (brand name Ubrelvy) are in this class of treatment. (Rimegepant has also been approved for use as a preventive treatment.)

Another new kind of acute treatment is lasmiditan (brand name Reyvow). Like triptans, ditans target serotonin receptors. Unlike triptans, ditans are choosy about which receptors they work on, and because they’re so choosy, they don’t constrict blood vessels and carry the same risk for people with high blood pressure or cardiovascular risks.

There’s also an old-school migraine medication in a brand-new form that may be a good option for you. Trudhesa is a nasal spray using dihydroergotamine (DHE), a medication that’s been used since the 1940s for acute migraine treatment. But old DHE treatments were expensive, awkward (difficult-to-use nasal formulas), or both. Trudhesa uses a unique nasal applicator that propels the DHE into the upper nasal cavities, where the tissues are rich with blood vessels and can absorb more medication with much less postnasal drip than traditional nasal sprays that target only the lower nasal passages.

The good news is that these newer treatments may help people who can’t take triptans or didn’t get great results with them. The bad news is that, because they’re new, there are no generic versions available. In the United States, that means they’re expensive and insurers may not want to cover them right away. Insurers will often require that people try “step therapy,” which means trying several kinds of less-expensive medications first. Talk to your doctor about documenting all the treatments you’ve tried that didn’t work, as well as treatments that are contraindicated. Good documentation can help you cut through the red tape.

Do the New Treatments Work?

But how well do these new treatments work? An intriguing analysis from 2021 suggests they play an important role for people who can’t use triptans. The authors analyzed several published studies to compare triptans, gepants, and lasmiditan. Although triptans scored higher on relief from pain and most bothersome migraine symptoms compared with the gepants and lasmiditan, these new treatments provided significant help for a smaller percentage of people. That means that people who may not be able to take triptans safely, have side effects from triptans, or do not get a benefit from triptans now have options.

Final Thoughts

Triptans are still the go-to acute treatment for many people with migraine for good reason. They come in different formulas and forms that may help you get relief and get more of your life back from migraine. If triptans aren't a good fit for you, there are new acute treatments available that may get the job done! Talk to your doctor about your migraine attacks, other healthcare concerns, and see if one of these acute treatments is right for you.

Angie Glaser

Angie Glaser is the Senior Digital Producer and Editor at Migraine Again and author of the blog Chronic Migraine Life. She has been featured on the Migraine World Summit and PBS News Hour as a patient advocate, and she has advised industry and nonprofit leaders on patient needs.