A busy clinic is not the best setting within which to explain the nuances of oral triptan therapy, and even writing the same directions on 1 prescription after another rapidly loses whatever charms the act once may have possessed. This month’s “tool” is a patient information sheet that some clinicians hopefully will find useful.
Oral and Intranasal Triptan Therapy for Acute Migraine Headache
The “triptans” are a family of drugs that were developed to treat acute migraine headache. Your doctor has prescribed for you 1 of the oral triptans: Imitrex (sumatriptan), Amerge (naratriptan), Zomig (zolmitriptan), Maxalt (rizatriptan), Axert (almotriptan), Frova (frovatriptan), or Relpax (eletriptan). Alternatively, he/she may have prescribed 1 of the 2 triptans marketed as nasal sprays: Imitrex nasal spray or Zomig nasal spray.
Although all of the oral and intranasal triptans initially were investigated for the treatment of migraine headache of moderate to severe intensity and were superior to placebo in those pivotal trials, they appear to be more consistently effective when used to treat migraine earlier in the attack, when the headache is still mild to moderate. Ideally, the oral or intranasal triptans should be used as follows.
Take 1 tablet (or administer 1 spray) for early/mild headache. This dose may be repeated after 2 hours. Do not use more than 2 doses within a 24-hour period, and do not use the triptans more than 2 days/week on a chronic basis.
Frova and Amerge have a slower onset of action and longer biologic half-life in the body than the other triptans, and it is probably best to use them particularly early in an attack. The intranasal triptans, Imitrex nasal spray and Zomig nasal spray, tend to have a faster onset of action than the orally administered triptans, and some patients find that they are more effective than their oral counterparts in attempting to treat headaches than have progressed to a higher level of pain intensity. Zomig and Maxalt are sold in “melt” formulations as well as in tablet form; while the “melt” formulation may be more convenient (no liquid is required to wash them down) and may be preferred by patients who have migraine-associated nausea, there is no evidence to suggest that they work faster than the tablet formulations.
Potential side effects of the triptans include nausea; jaw, neck, or chest tightness, pressure or squeezing; rapid heart rate; fatigue; numbness-tingling (especially involving the face); or a burning sensation over the skin. While these and other side effects are not uncommon, the triptans are a very safe class of medications when used appropriately by the patients for whom they are indicated. Interestingly, side effects seem to be less likely to occur when the triptan is taken early in the migraine attack.
The triptans are not effective for all migraine patients and will not stop every headache even in those patients who do benefit from the drugs. Furthermore, if your response to the triptan you have been prescribed is less than desired, it may make sense to move on and try another.
Contraindications to the use of the triptans include coronary artery disease, a history of stroke, uncontrolled high blood pressure, and co-administration of certain other medications. Check with your physician regarding the last, and confirm that the medications you are taking are safe to use with the triptans.
John F. Rothrock, MD