From the Guidelines
The most effective triptan for migraine is sumatriptan, due to its extensive clinical experience and availability in multiple formulations, including oral tablets, nasal spray, and injectable forms, as supported by the latest guideline from the American College of Physicians 1. When selecting a triptan, it's essential to consider individual patient preferences, such as route of administration and cost. The choice of a specific triptan, including almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan, should be based on individualized decision making 1. Some key points to consider when using triptans for migraine treatment include:
- Starting with a low dose, such as 50mg of sumatriptan, and potentially increasing to 100mg if needed
- Using a nonoral triptan and an antiemetic in people with severe nausea or vomiting
- Avoiding opioids or butalbital for the treatment of acute episodic migraine
- Counseling patients to begin treatment as soon as possible after migraine onset, using combination therapy to improve efficacy
- Considering the addition of preventive medications if episodic migraine occurs frequently or treatment does not provide an adequate response 1. It's also important to note that triptans work by binding to serotonin receptors, constricting blood vessels, and reducing inflammation in the brain, but may have side effects such as chest tightness, fatigue, and dizziness, and should be avoided in patients with cardiovascular disease, uncontrolled hypertension, or during pregnancy.
From the Research
Efficacy of Triptans in Migraine Treatment
- Sumatriptan is a selective agonist at serotonin 5-HT1-like receptors, including 5-HT1B/1D subtypes, and is an effective treatment for acute migraine attacks 2.
- Eletriptan, another triptan, has a rapid onset of action and demonstrates superiority over placebo as early as 30 minutes after administration, with efficacy similar to or greater than sumatriptan for most endpoints 3.
- Sumatriptan formulations have different pharmacokinetic, efficacy, and adverse event profiles, with the fastest and most complete migraine relief occurring with subcutaneous dosing 4.
Comparison of Triptans
- Eletriptan 40 mg was generally superior to naratriptan 2.5 mg and equivalent to almotriptan 12.5 mg, rizatriptan 10 mg, and zolmitriptan 2.5 mg, while eletriptan 80 mg was superior to zolmitriptan 2.5 mg for most efficacy parameters 3.
- Sumatriptan 50 mg and 100 mg were each superior to sumatriptan 25 mg in reducing moderate or severe predose headache to mild or no headache 4 hours postdose 5.
Route of Administration
- Subcutaneous administration of sumatriptan was the most effective, with pain reduced from moderate or severe to none by two hours in almost 6 in 10 people, compared with approximately 1 in 7 taking placebo 6.
- Oral, rectal, and intranasal sumatriptan also provided clinically useful pain relief, with the oral 50 mg dose providing complete relief of pain in almost 3 in 10 people compared with about 1 in 10 after placebo 6.
Adverse Events
- Adverse events were generally of mild or moderate severity, of short duration, and more common with subcutaneously administered sumatriptan and higher doses of oral and intranasal sumatriptan than with other dose and route combinations 6.
- The incidence of adverse events with 25-mg and 50-mg sumatriptan tablets was similar to the incidence with placebo and lower than the incidence with 100-mg sumatriptan tablets 5.