From the Guidelines
Rizatriptan (Maxalt) is generally preferred over sumatriptan (Imitrex) for acute migraine attacks due to its faster onset of action and higher efficacy, as supported by the most recent clinical guideline from the American College of Physicians 1.
Key Considerations
- The choice between sumatriptan and rizatriptan should be based on individualized decision making, taking into consideration patient preferences on factors such as route of administration and cost.
- Both medications are effective in treating acute migraine attacks, but rizatriptan typically works within 30 minutes compared to sumatriptan's 45-60 minutes.
- Rizatriptan is usually prescribed as a 10mg tablet (5mg for patients on propranolol) taken at migraine onset, with a maximum of 30mg in 24 hours.
- Sumatriptan comes in multiple formulations, including tablets (25-100mg), nasal spray, and injections, with the injectable form working fastest but causing more side effects.
Important Safety Information
- Neither sumatriptan nor rizatriptan should be taken within 24 hours of other triptans or ergotamines.
- Both medications are contraindicated in patients with cardiovascular disease, uncontrolled hypertension, or hemiplegic/basilar migraines.
- Side effects for both include chest tightness, fatigue, dizziness, and nausea, though rizatriptan typically causes fewer side effects overall.
Clinical Guideline Recommendations
- The American College of Physicians recommends considering the use of triptans, including sumatriptan and rizatriptan, for the treatment of acute episodic migraine headache in outpatient settings 1.
- The guideline also suggests that patients who do not tolerate or have inadequate response to a recommended migraine treatment may respond to another within the same drug class.
From the Research
Comparison of Sumatriptan and Rizatriptan
- Both sumatriptan and rizatriptan are triptans, a class of medications commonly used to treat acute migraine attacks 2, 3, 4, 5.
- Triptans work by constricting blood vessels and blocking pain pathways in the brain, providing relief from migraine symptoms such as headache, nausea, and sensitivity to light and sound 2, 3, 4, 5.
- Sumatriptan is one of the most widely prescribed acute migraine therapies, but it has low oral bioavailability and some problematic adverse effects 6.
- Rizatriptan is also effective in treating migraine attacks, with a faster onset of action compared to sumatriptan in some studies 2, 3, 5.
Efficacy and Safety
- A study comparing diclofenac-potassium, sumatriptan, and placebo found that diclofenac-potassium was more effective than placebo in reducing migraine headache pain at 2 hours after dosing, and had a faster onset of action compared to sumatriptan 6.
- Another study found that triptans, including sumatriptan and rizatriptan, are highly effective in treating migraine attacks, with minor differences in efficacy, headache recurrence, and adverse effects between the different triptans 2.
- The American Headache Society recommends triptans, including sumatriptan and rizatriptan, as first-line treatments for acute migraine attacks, along with nonsteroidal anti-inflammatory drugs (NSAIDs) and combination analgesics 3, 5.
Treatment Guidelines
- The Taiwan Headache Society recommends a stratified care approach, with oral NSAIDs as the first choice for mild to moderate migraine attacks, and oral or nasal spray triptans for moderate to severe attacks 5.
- The society also recommends that the administration of triptans and NSAIDs should follow the concept of "stratified care", with the goal of providing effective treatment while minimizing adverse effects and preventing medication-overuse headache 5.
- The use of acute treatment should be limited to a maximum of ten days a month to prevent medication-overuse headache 5.