What is the recommended dosing for triptans (serotonin receptor agonists) in the treatment of migraine?

Triptan Dosing for Migraine Treatment

The recommended dosing for triptans in acute migraine treatment begins with a single dose at onset of headache, with possible redosing after 2 hours if needed, not exceeding maximum daily limits specific to each triptan. 1

Initial Dosing Recommendations

Oral Triptans

• Sumatriptan: 50-100 mg initially (100 mg may provide greater effect but with more side effects)
• Rizatriptan: 5-10 mg initially (10 mg may be more effective)
• Zolmitriptan: 2.5-5 mg initially
• Eletriptan: 20-40 mg initially (40 mg shows greater response)
• Naratriptan: 1-2.5 mg initially
• Almotriptan: 6.25-12.5 mg initially
• Frovatriptan: 2.5 mg initially

Non-oral Formulations (for patients with significant nausea/vomiting)

• Sumatriptan subcutaneous: 6 mg
• Sumatriptan intranasal: 5-20 mg
• Zolmitriptan intranasal: 5 mg

Redosing Guidelines

• If migraine persists after 2 hours, a second dose may be administered 2, 3
• Maximum daily doses:
  • Rizatriptan: 30 mg in 24 hours 2
  • Eletriptan: 80 mg in 24 hours 3
  • Sumatriptan: 200 mg oral or 12 mg subcutaneous in 24 hours

Special Dosing Considerations

Drug Interactions

• Patients taking propranolol:
  • Adults: Only 5 mg rizatriptan is recommended, maximum 3 doses (15 mg) in 24 hours 2
  • Pediatric patients ≥40 kg: Only a single 5 mg dose of rizatriptan in 24 hours
  • Rizatriptan should not be given to propranolol-treated pediatric patients <40 kg 2

Pediatric Dosing (6-17 years)

• Rizatriptan:
  • <40 kg: 5 mg
  • ≥40 kg: 10 mg
  • Maximum: One dose in 24 hours 2

Administration Timing and Strategy

• Begin treatment as soon as possible after migraine onset 1
• Consider combination therapy (triptan with NSAID or acetaminophen) for improved efficacy 1
• For patients with significant nausea or vomiting, use non-oral formulations and consider adding an antiemetic 1

Contraindications and Precautions

• Triptans should not be used in patients with:
  • Ischemic heart disease or coronary vasospasm
  • Uncontrolled hypertension
  • Basilar or hemiplegic migraine
  • Within 24 hours of another triptan or ergot-containing medication 3
  • Within 72 hours of potent CYP3A4 inhibitors (for eletriptan) 3

Medication Overuse Warning

• Limit triptan use to ≤10 days per month to avoid medication overuse headache 1
• The safety of treating more than 3-4 migraines in a 30-day period has not been established 2, 3

Clinical Pearls

• If a patient doesn't respond to one triptan, they may respond to another within the same class 1
• The 50 mg dose of sumatriptan has been shown to have a good effectiveness-to-tolerability ratio for many patients 4, 5
• For patients with frequent attacks, consider preventive therapy rather than increasing acute medication use 1
• Counsel patients to treat attacks early, as triptans are more effective when taken at the onset of pain rather than when pain is severe 6

Remember that triptan selection should be based on individual factors including headache severity, speed of onset, duration of effect needed, and side effect profile.