What are the indications to start triptans (serotonin receptor agonists) for migraine treatment?

Indications for Starting Triptans in Migraine Treatment

Triptans are indicated as second-line therapy for the acute treatment of moderate to severe migraine attacks when first-line over-the-counter analgesics (NSAIDs) provide inadequate headache relief. 1

Primary Indications

• Acute treatment of migraine with or without aura in adults 2, 3
• Second-line therapy after inadequate response to first-line medications (NSAIDs, acetaminophen) 1, 4
• Moderate to severe migraine attacks that don't respond to initial treatment 1

Key Requirements Before Starting Triptans

• A clear diagnosis of migraine must be established 2, 3
• Patient should have tried and had inadequate response to first-line treatments:
  • NSAIDs (aspirin, ibuprofen, diclofenac potassium)
  • Acetaminophen (less efficacious than NSAIDs) 4

Optimal Timing and Administration

• Triptans are most effective when taken early in an attack while headache is still mild 4
• Should not be used during the aura phase of a migraine attack 4
• Treatment should begin as soon as possible after migraine onset 1

Contraindications

Triptans should not be used in patients with:

• History of coronary artery disease or coronary artery vasospasm 2
• Wolff-Parkinson-White syndrome or other cardiac conduction disorders 2
• History of stroke, transient ischemic attack, hemiplegic or basilar migraine 2
• Peripheral vascular disease or ischemic bowel disease 2
• Uncontrolled hypertension 2
• Recent (within 24 hours) use of another triptan or ergotamine-containing medication 2
• Concurrent or recent (past 2 weeks) use of MAO-A inhibitors 2
• Severe hepatic impairment 2

Special Considerations

• If one triptan is ineffective, others might still provide relief 4
• For patients with severe nausea/vomiting, consider non-oral triptan formulations (nasal, injectable) 1
• Sumatriptan subcutaneous injection can be useful for patients who:
  • Rapidly reach peak headache intensity
  • Cannot take oral triptans due to vomiting
  • Have failed other triptans 4

Monitoring and Precautions

• Monitor for medication overuse headache (≥10 days/month with triptans) 1
• Maximum dose in a 24-hour period: 200 mg for sumatriptan 2
• A second dose should only be considered if some response to the first dose was observed 2
• Separate doses by at least 2 hours 2

Treatment Algorithm

1. First-line treatment: NSAIDs (aspirin, ibuprofen, diclofenac) or acetaminophen for mild attacks
2. Second-line treatment: Add triptan if inadequate response to first-line treatment
3. For triptan failure:
   • Try a different triptan (if one fails, others may work) 4
   • Consider combination therapy (triptan + NSAID) 1
   • For multiple triptan failures, consider third-line options like ditans (lasmiditan) or gepants (ubrogepant, rimegepant) 4

Common Pitfalls to Avoid

• Using triptans for prophylactic therapy of migraine (not indicated) 2, 3
• Using triptans for treatment of cluster headache without proper diagnosis 2, 3
• Administering triptans during the aura phase 4
• Exceeding recommended maximum daily doses 2
• Failing to recognize medication overuse headache from frequent triptan use 1
• Using triptans in patients with cardiovascular contraindications 2

Remember that triptans are not indicated for the prevention of migraine attacks but specifically for acute treatment when a clear diagnosis of migraine has been established 2, 3.