What are alternative therapies to Triptans (serotonin receptor agonists) for migraine treatment?

Alternative Therapies to Triptans for Migraine Treatment

NSAIDs are the first-line alternative to triptans for migraine treatment, with ibuprofen (400-800 mg), naproxen sodium (500-550 mg), and aspirin having the most consistent evidence for efficacy. 1

First-Line Alternatives to Triptans

NSAIDs

• Ibuprofen: 400-800 mg orally for mild to moderate migraines 1
• Naproxen sodium: 500-550 mg orally 1
• Aspirin: Effective as monotherapy 2
• Combination therapy: Acetaminophen + aspirin + caffeine shows superior efficacy compared to individual components 1
• Tolfenamic acid: Demonstrated consistent evidence of efficacy 2

Antiemetics

• Metoclopramide: 10 mg IV can be used as monotherapy for acute attacks, particularly beneficial for patients with nausea and vomiting 2, 1
• Prochlorperazine: 10 mg IV with diphenhydramine 25 mg IV is recommended as second-line therapy 1

Second-Line Alternatives

Ergot Derivatives

• Dihydroergotamine (DHE): Good evidence for efficacy as intranasal monotherapy 2

  • Available in parenteral preparations and nasal spray
  • More appropriate for severe migraines 2
  • Contraindicated in pregnancy due to oxytocic properties 2
  • Should not be used chronically due to potential for peripheral vasoconstriction 2

• Ergotamine-caffeine combinations: Evidence is inconsistent, and frequent adverse events are documented 2

  • Available as oral preparations and rectal suppositories 2
  • Limited use due to potential for medication-overuse headaches, ergot poisoning, and negative effects on prophylactic medications 2

Opioids

• Butorphanol nasal spray: Good evidence for efficacy 2
• Opioids should be reserved for when other medications cannot be used, when sedation is not a concern, or when the risk of abuse has been addressed 2
• Limit use to avoid dependency and eventual loss of efficacy 1

Non-Pharmacologic Alternatives

Several non-pharmacologic approaches have shown effectiveness in migraine management:

• Relaxation training: Effective in preventing migraines 2
• Thermal biofeedback combined with relaxation training: Effective preventive strategy 2
• Electromyographic biofeedback: Demonstrated effectiveness 2
• Cognitive-behavioral therapy: Effective for prevention 2, 1

Combination Approaches

For enhanced efficacy, consider these combinations:

• NSAID + triptan: Strong recommendation for moderate to severe migraine headaches (if triptans can be used in limited capacity) 1
• Behavioral therapy + preventive medication: May achieve additional clinical improvement 2

Preventive Medications

For patients with frequent migraines (≥2 days/month), consider these preventive options:

• Beta blockers: Propranolol (80-240 mg/day), metoprolol, atenolol 1
• Topiramate: Effective for prevention 1
• Candesartan: Recommended by the American Academy of Neurology 1
• Amitriptyline: 30-150 mg/day 1

Important Considerations and Caveats

• Avoid medication overuse to prevent rebound headaches 1
• Acetaminophen alone is ineffective for migraine treatment 2
• When selecting alternatives to triptans, consider the patient's cardiovascular status, pregnancy status, and history of medication response
• For patients with nausea and vomiting, non-oral routes of administration may be preferable
• Monitor for side effects with all medications, particularly cardiovascular effects with ergot derivatives

The stratified-care approach (assigning treatment based on migraine severity) is superior to the step-care approach (starting with safest, least expensive options and progressing to more expensive medications) 2. This should guide your selection of alternatives to triptans based on the severity of the patient's migraine symptoms.