What is the most suitable triptan (serotonin receptor agonist) for elderly patients?

From the Guidelines

Sumatriptan is generally considered the best triptan for elderly patients due to its established safety profile and extensive clinical experience. For elderly patients, starting with a lower dose of 25-50mg orally is recommended, which can be repeated after 2 hours if needed, not exceeding 200mg in 24 hours 1. Alternatively, the nasal spray (5-20mg) or subcutaneous injection (4-6mg) may be used for faster relief. Elderly patients should use triptans with caution due to increased cardiovascular risk, and a thorough cardiovascular assessment is advisable before starting treatment 1.

Key Considerations

• Frovatriptan and naratriptan are good alternatives as they have longer half-lives and fewer side effects, making them particularly suitable for older patients with prolonged migraines 1.
• These medications work by binding to serotonin receptors, constricting cranial blood vessels and inhibiting pain pathways.
• Elderly patients should be monitored for side effects such as chest tightness, fatigue, and dizziness, and triptans should be avoided in those with uncontrolled hypertension, coronary artery disease, or stroke history 1.

Monitoring and Precautions

• Regular monitoring of blood pressure is necessary for older patients with migraine who use triptans 1.
• Periodical assessment of cardiovascular risk factors is also recommended 1.
• Clinicians should be aware of the potential for increased risk of cerebrovascular or cardiovascular events in older people, although no robust evidence supports this risk 1.

Treatment Approach

• A stepped care approach may be used, starting with NSAIDs and antiemetics, and progressing to triptans if necessary 1.
• Preventive therapy may be indicated for patients with frequent or severe migraine attacks, and should be tailored to the individual patient's needs 1.

From the FDA Drug Label

Mean AUC of frovatriptan was 1. 5- to 2-fold higher in healthy elderly subjects (age 65 – 77 years) compared to those in healthy younger subjects (age 21 - 37 years). Mean blood concentrations of frovatriptan in elderly subjects were 1. 5- to 2-times higher than those seen in younger adults Because migraine occurs infrequently in the elderly, clinical experience with FROVA is limited in such patients.

The best triptan for the elderly is not explicitly stated in the provided drug labels. However, based on the available information, frovatriptan may be considered due to its pharmacokinetic profile in elderly subjects.

• The mean AUC of frovatriptan was 1.5- to 2-fold higher in healthy elderly subjects compared to younger subjects.
• Mean blood concentrations of frovatriptan in elderly subjects were 1.5- to 2-times higher than those seen in younger adults. It is essential to exercise caution and carefully evaluate the potential benefits and risks when prescribing triptans to elderly patients, considering their limited clinical experience with these medications 2.

From the Research

Efficacy of Triptans in the Elderly

• There are no specific studies provided that directly compare the efficacy of triptans in the elderly population.
• However, the studies provided compare the efficacy of eletriptan with other triptans, such as sumatriptan, naratriptan, almotriptan, rizatriptan, and zolmitriptan, in the general population 3, 4, 5.
• Eletriptan has been shown to be effective in the acute treatment of migraine attacks, with a rapid onset of action and superiority over placebo 3, 4, 5.
• The efficacy of eletriptan has been compared to other triptans, with results showing that eletriptan 40 and 80 mg are consistently superior to ergotamine/caffeine and have a similar or superior efficacy to other triptans, such as sumatriptan, naratriptan, almotriptan, rizatriptan, and zolmitriptan 3, 5.

Safety and Tolerability of Triptans in the Elderly

• The safety and tolerability of triptans in the elderly population are not directly addressed in the provided studies.
• However, the studies suggest that eletriptan is generally well tolerated, with adverse events being transient and mild to moderate in intensity 3, 4, 5.
• The study by 6 reviews the recent data on eletriptan's clinical efficacy, safety, and tolerability, and potential clinically relevant interactions with other drugs, but does not specifically address the elderly population.

Pharmacological Approaches to Migraine

• The study by 7 summarizes new treatment options for the therapy of acute migraine attacks and migraine prophylaxis, including the use of triptans, such as eletriptan.
• The study suggests that triptans are highly effective in treating migraine attacks, improving headache, nausea, photo- and phonophobia, and have minor differences in efficacy, headache recurrence, and adverse effects 7.