Imitrex vs. Maxalt, Zomig vs. Maxalt, Amerge vs. Relpax, Frova vs. Imitrex, Maxalt vs. Relpax, Zomig vs. Imitrex, Frova vs. Amerge, Imitrex vs. Treximet. Maxalt vs. Frova. Axert vs. Imitrex? Which triptan is the best for your migraine pain?
Which Triptan Is Best?
The triptans are for the acute treatment of migraine headaches and migraine symptoms. They were a ground breaking medication (and still are) for severe migraines. There are 7 triptans available and include Imitrex (Sumatriptan), Maxalt (Rizatriptan), Relpax (Eletriptan), Zomig (Zolmitriptan), Frova (Frovatriptan), Amerge (Naratriptan), Axert (Almotriptan), and Treximet (Sumatriptan/Naproxen). Different triptans have different options of drug administration including oral tablets, nasal spray, and injectable. So what are the best triptans to use?
First of all, the ergot based medications such as DHE (dihydroergotamine) and cafergot (ergotamine + caffeine) have been the oldest and most potent migraine abortive medications historically, and are still good options. However, the ergots can have more side effects (ergotamine more than DHE). The triptans are a refined derivative of these older medicines, with very selective receptor targets in how they work (as opposed to DHE which hits a wide variety of receptor targets).
Since 1992 when Sumatriptan became available, the triptans have been the first and only migraine specific abortive medications available. Triptan medications have been the standard of care migraine treatments for pain relief of acute migraine attacks since that time. Triptans are also used commonly for cluster headaches (injectable Sumatriptan or nasal spray Sumatriptan or Zolmitriptan).
In 2020, two new classes of migraine abortive medications became available (gepants (Ubrelvy, Nurtec, Zavspret) and ditans (Reyvow)), but until that time triptans and the ergots were the only migraine specific abortive options available.
How Do The Triptans Work?
Triptans work by turning on the serotonin receptors 5-HT1B and 5-HT1D. Activation of the 5-HT1B receptor helps to constrict (narrow) the dilated inflamed pain-producing blood vessels surrounding the brain which occurs during a migraine attack. The 5-HT1B receptors are also present in the brainstem, and likely play a role in modulating the electrical event of a migraine. Activation of the 5-HT1D receptors results in disrupting the trigeminal nerves from releasing inflammatory proteins such as CGRP (calcitonin gene-related peptide) around the brain and blood vessels, which contributes to pain during a migraine attack. This receptor also interferes with pain processing between the brainstem and the brain (helps to block this electrical transmission), and it helps to block the nausea and vomiting centers in the brainstem. Triptans also inhibit mast cell degranulation in the covering of the brain (meninges), which lessens the inflammation during a migraine.
What Are The Side Effects Of Triptans?
Most patients tolerate triptans well. However, some patients have adverse effects. So let’s discuss triptans side effects and triptan sensations. Just like any medicine, some patients may have side effects, while others don’t. Furthermore, about 30% of patients with migraine may not respond to triptans (triptan non-responder). If side effects do occur, there is some variability between the different types of triptans.
Potential common side effects of the triptans include palpitations or racing heart beat, nausea, tingling, numbness or flushing in the face or extremities, drowsiness, fatigue, dizziness, and tightness or pressure in the chest, neck, or jaw. Although the chest pressure is not common, it is usually of a muscular and not a non-cardiac (heart) cause, so it can be scary if you don’t know about this potential side effect. Adverse events can also occur. Chest pain could still potentially be a sign of heart attack in patients with vascular risk factors (blood pressure, cholesterol, smoking, diabetes, early family history of heard disease), and unknown coronary disease. The reason is because the triptans can cause slight vasoconstriction (narrowing) of arteries. So if there is already narrowing in an artery, increasing further narrowing could lead to lack of blood flow to the heart with subsequent heart attack in those at risk. There is an extremely rare potential for a neurologic disorder called serotonin syndrome when mixed with some other medication classes such as selective serotonin reuptake inhibitors.
When Should Triptans Not Be Used?
Triptans can cause mild artery constriction (narrowing) due to activity at the 5-HT1B receptor as discussed above. This could theoretically occur in narrowed arteries from cholesterol build up, such as in the heart. Therefore, triptans should not be used in patients who have coronary artery disease, cerebrovascular disease (stroke), peripheral arterial disease, or uncontrolled risk factors for these diseases (high blood pressure, cholesterol, diabetes, smoking, family history of early heart disease) because chest pain for them could truly represent heart attack. If there is concern for the possibility of underlying cardiovascular disease, a cardiac stress test should be performed prior to triptan prescription.
Triptans are also considered to be contraindicated in patients with visual snow, persistent migraine aura, and migrainous stroke (infarction) due to theoretical concerns of vasoconstriction potentially causing stroke. This contraindication has historically also included hemiplegic migraine (now called migraine with motor aura) and basilar migraine (now called migraine with brainstem aura). When the triptan studies were done years ago, they excluded patients with these forms of migraine due to the vascular theory of migraine at that time. The vascular theory of migraine assumed that vasoconstriction and lack of blood flow was the cause of aura and neurologic features with migraine. So the thinking was that if you cause further vasoconstriction with a triptan, you may cause stroke. However, we now know that these phenomena are of an electrical basis and not a vascular basis. Therefore, many specialists have gotten more liberal with the use of triptans in patients with hemiplegic or basilar migraine, and there have been a number of case series and case reports of these patients using triptans without any problems. However, larger confirmatory studies are needed.
Patients that can not use triptans due to side effects, or if they have any of these medical contraindications noted above, should consider one of the newer types of migraine abortive medications available with either the gepants (Ubrelvy, Nurtec, Zavspret), ditans (Reyvow) or neuromodulatory devices. These newer options have a much lower side effect profile, can be taken in the setting of the medical contraindications to triptans mentioned above, and work by an entirely different mechanism of action.
It is also important to know that triptans can cause medication-overuse headache (rebound headache) if used consistently greater than 10 days per month on average. The result is that the headache continues to worsen in frequency and/or severity. This also happens with NSAIDs, over the counter pain meds, and other types of as-needed pain medications. Notably, the gepants do not cause rebound headache. If triptans, or any migraine abortive medication, is having to be used at this high frequency, a preventive treatment should be used until the migraine and headache frequency is significantly improved consistently for several months. This can be done with a variety of medications which may also include the CGRP monoclonal antibody (mAb) treatments, Botox, natural supplements, herbals and vitamins, or neuromodulatory devices.
What Is The Best Triptan To Use?
Triptans are all similar in how they work, although some people may respond better to one versus another. There are many differences between the triptans which allow them to be fine-tuned towards different types of migraine characteristics, as discussed below. This is a very important clinical point that is almost always overlooked by most physicians prescribing these medications if they are not headache specialists.
Tailoring triptans to specific migraine characteristics can make a dramatic difference in effectiveness. The information below can be discussed with your doctor to choose a triptan that might be better personalized to your migraine features.
List Of Triptans:
-Sumatriptan: oral, subcutaneous injection, needle-less subcutaneous injection, nasal spray, breath-powered intranasal delivery system
-Zolmitriptan: oral, orally dissolvable tablet, nasal spray
-Rizatriptan: oral, orally dissolvable tablet
-Almotriptan: oral
-Eletriptan: oral
-Sumatriptan/Naproxen: oral
-Frovatriptan: oral
-Naratriptan: oral
Group 1 Triptans:
-Faster onset of action, higher potency (thus can have higher side effect potential), higher 24-hour migraine recurrence
-Sumatriptan, Sumatriptan/Naproxen, Zolmitriptan, Rizatriptan, Almotriptan, Eletriptan
Group 2 Triptans:
-Slower onset of action, lower potency (thus often have lower side effect potential), lower 24-hour migraine recurrence since half life is longer
-Frovatriptan, Naratriptan
Fine-Tuning The Best Triptan Choice For You:
(Remember The Mnemonic CORN, And This Will Help To Narrow Down The Best Triptan To Consider):
Contraindications
Onset to peak pain
Recurrence of migraine after treatment
Nausea and vomiting severity
Contraindications:
This is not an exhaustive list, but are the most common. Your doctor should be well aware of when triptans should not be used. Here are some:
-Known vascular disease (coronary artery disease, peripheral vascular disease, history of stroke)
-Vascular risk factors (poorly controlled hypertension, hyperlipidemia, diabetes, smoking, premature family history of coronary artery disease (men less than age 55, women less than age 65), postmenopausal women, etc.
-Kidney or liver failure
-Prinz-Metal angina
Onset to migraine peak pain:
-Group 1 triptan (quicker onset) is usually more useful than a Group 2 triptan (slower onset) for fast onset migraine attacks.
-Subcutaneous injection (Sumatriptan) or nasal spray (Sumatriptan, Zolmitriptan) will typically be more effective than an oral triptan if the patient wakes with migraine already ongoing (waking migraine), or if the migraine hits its peak pain level within 30 minutes (fast onset). Rizatriptan is the fastest of the pill triptans, and can sometimes still catch waking migraine.
-If migraine builds with slow onset, either a Group 1 or 2 triptan can be used.
Return of migraine after treatment:
-If migraine recurrence occurs within 24 hours (for example it goes away with the triptan, but keeps returning later in the day or the next day), or the migraine is usually multiple consecutive days long (such as menstrual migraine):
-Combine the 1st dose of the triptan with an NSAID (such as Naproxen) OR
-Use a group 2 triptan (Naratriptan vs. Frovatriptan)
Nausea and vomiting severity:
-If nausea and vomiting occur early in the attack, or are severe to where it is hard to keep a pill down without vomiting it back up:
-A subcutaneous injection (Sumatriptan) or nasal spray (Sumatriptan, Zolmitriptan) should be used.
-Of note, dissolvable triptan tablets are still absorbed by the gastrointestinal tract, not sublingually. So, vomiting will still make this route ineffective, similar to a regular pill.
Triptan Pearls In Further Fine-Tuning Triptan Choices:
Sumatriptan:
-Highest potency (in subcutaneous form) and quickest onset (subcutaneous > nasal spray) of triptans
-Greatest flexibility is dosing route options
Rizatriptan:
-Fastest onset of oral triptans
-Greatest likelihood of 2h pain-free and sustained pain-free response
-Propranolol increases its serum concentration, so 5mg per dose should be if used together
Zolmitriptan:
-Most likely to treat persistent headache when 1st dose fails
Almotriptan:
-Group 1 triptan with the least side effects
Eletriptan:
-Highest potential for drug interactions. Decrease dosage with CYP3A4 drugs such as macrolides, fungal, HIV, etc.
Naratriptan:
-The “gentle triptan” with the least side effects given its slower onset of action
-Low 24 hour migraine recurrence rate
-Good choice to give shortly prior to an expected and known migraine trigger (menstruation, air travel, etc.)
Frovatriptan:
-Low side effect potential given its slower onset of action
-Longest half life (26 hours)
-Low 24 hour migraine recurrence rate
-Good choice to give shortly prior to an expected and known migraine trigger (menstruation, air travel, etc.)
Can You Combine A Triptan And A Gepant In The Same Day?
Yes, you can use a triptan and an abortive gepant such as Nurtec, Ubrelvy, or Zavspret in the same day. Migraine patients should have a war chest to use if the first medicine fails. The gepants fit in nicely to this scenario in that they can be used together with a triptan.
Just a reminder though that you can not combine triptans and DHE (dihydroergotamine) in the same 24 hours.
Conclusions:
The triptans were a game changer for millions of migraine patients in aborting migraine attacks. Using the highest available triptan dose is also generally recommended to see the full effect. We see many patients who have “failed triptans”, but on further history they were put on very low doses (such as 25 mg sumatriptan, when 100 mg is the standard dose). Even so, about 30% of migraineurs do not respond to triptans, only 1/3rd are pain-free at 2 hours, and only 17-25% remain pain-free at 24 hours. Therefore, although the majority respond well to triptans, not everyone does. Luckily, there are other medication options including the newer classes of migraine abortive medications (gepants, ditans) now available.
@neuralgroover How to pick the best triptan for you and your specific migraine characteristics! #triptan #triptans #sumatriptan #sumatriptaninjectable #rizatriptan #zolmitriptan #eletriptan #naratriptan #frovatriptan #almotriptan #migraine #migraineabortive #headache #migrainetreatment #migrainemedicine #migraineattack #migraineattacks #ChronicMigraine #MigraineAwareness #migrainerelief #migraines #foryou #fyp #tiktok #foryoupage #explore #trending #learnontiktok #lifehacks #health #wellness #education #migrainesufferer #MigraineWarrior #MigraineSucks #headaches #migrainesociety #migrainetok #migrainetiktok #neurologytiktok #neurology #neuro #neuroscience #neurotok #headachetiktok #serotonin #medical #medicaltiktok #primarycareprovider #doctorsoftiktok #doctor #physiciansoftiktok #physician #pcp #pa #np #migrainetips #headachetips #headachespecialist #neurologist #pain #migrainerelieftok #migrainelife #migrainecommunity #MedicalEducation #meded #medicaltips #healthcare #migrainecheck #migraineremedies #headachehacks #headachehack #blog #blogger #blogging #Blogtok #Blogtiktok #MigraineBlog #MigraineBlogger #HeadacheBlog ♬ original sound – Neuralgroover
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