Qualification for Triptan Medications
To qualify for triptan medications, a patient must have a clear diagnosis of migraine or cluster headache that meets the International Classification of Headache Disorders (ICHD-3) criteria, with no contraindications such as cardiovascular disease, uncontrolled hypertension, or recent use of other serotonergic medications. 1, 2, 3, 4
Diagnostic Criteria Required for Triptan Prescription
For Migraine Without Aura
To qualify for triptans, patients must meet these criteria:
- At least five attacks fulfilling the following:
- Headache lasting 4-72 hours (untreated/unsuccessfully treated)
- At least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by routine physical activity
- At least one of: nausea/vomiting, photophobia and phonophobia
- Not better explained by another diagnosis 1
For Migraine With Aura
- At least two attacks with reversible aura symptoms (visual, sensory, speech/language, motor, brainstem, or retinal)
- At least three of the following characteristics:
- Aura symptom spreads gradually over ≥5 minutes
- Two or more symptoms occur in succession
- Each symptom lasts 5-60 minutes
- At least one symptom is unilateral
- At least one symptom is positive
- Aura accompanied by or followed by headache within 60 minutes 1
For Cluster Headache
- Subcutaneous sumatriptan (6 mg) or intranasal zolmitriptan (10 mg) may be prescribed for acute treatment of cluster headache attacks 1, 5
Absolute Contraindications to Triptan Use
Triptans are contraindicated in patients with:
- History of coronary artery disease or coronary artery vasospasm
- Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders
- History of stroke, transient ischemic attack, or hemiplegic/basilar migraine
- Peripheral vascular disease
- Ischemic bowel disease
- Uncontrolled hypertension
- Recent (within 24 hours) use of another triptan or ergotamine-containing medication
- Concurrent or recent (past 2 weeks) use of monoamine oxidase-A inhibitor
- Hypersensitivity to triptans
- Severe hepatic impairment 2, 6
Warnings and Precautions
Triptans should be used with caution in patients with:
- Multiple cardiovascular risk factors (requires cardiac evaluation before prescription)
- History of arrhythmias
- Risk of cerebral hemorrhage or stroke
- Risk of gastrointestinal ischemic reactions
- History of seizures or lowered seizure threshold 2
Important Considerations for Prescribing
Cardiovascular Risk Assessment:
- Approximately 20% of migraine patients have cardiovascular conditions that contraindicate triptan use
- An additional 25% have ≥2 cardiovascular risk factors that require caution 7
Medication Overuse Prevention:
Triptan Selection Algorithm:
- First-line options: eletriptan, frovatriptan, rizatriptan, sumatriptan, or zolmitriptan 1
- For severe attacks or significant nausea/vomiting: subcutaneous sumatriptan 6mg 6
- For patients with hepatic impairment: maximum single dose should not exceed 50mg 2
- If one triptan fails, try another as response can be idiosyncratic 6
Evaluation of Effectiveness:
- A triptan should be tried for 2-3 headache episodes before determining effectiveness
- Treating during the mild pain phase provides better outcomes than waiting until pain is moderate or severe 6
Monitoring and Follow-up
- Track frequency, severity, and medication use with a headache diary
- Schedule follow-up in 4-6 weeks to assess effectiveness
- Consider referral to a neurologist or headache specialist if no improvement after trials of 2-3 preventive medications 6