Treatment for Migraine After Triptan Failure
After triptan failure, the next treatment steps include CGRP antagonists (gepants) such as rimegepant or ubrogepant, or ditans such as lasmiditan, as third-line medications for acute migraine management. 1, 2
Defining Triptan Failure
Triptan failure occurs when:
- No or insufficient therapeutic response in at least three consecutive attacks
- Contraindications to triptan use exist (cardiovascular conditions, age ≥65 years)
- Intolerable side effects develop
Treatment Algorithm After Triptan Failure
1. Third-Line Acute Medications
CGRP Antagonists (Gepants)
- Rimegepant
- Ubrogepant
- Zavegepant
- High strength of evidence for efficacy 2
- Advantage: No driving restrictions, safer cardiovascular profile than triptans
Ditans
2. Adjunct Medications
- Antiemetics when nausea/vomiting is prominent
- Prokinetic antiemetics such as domperidone 1
3. Consider Preventive Therapy
Especially important when triptan failure occurs, consider preventive therapy if:
- Migraines occur ≥2 times per month
- Attacks are prolonged and disabling
- Quality of life is reduced between attacks 2
Preventive Medication Options:
First-line preventives:
- Beta-blockers (propranolol 80-240 mg/day, timolol 20-30 mg/day)
- Tricyclic antidepressants (amitriptyline 30-150 mg/day)
- Anticonvulsants (topiramate 100 mg/day, divalproex sodium 500-1500 mg/day) 2
For inadequate response:
- CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 2
4. Alternative Acute Treatment Options
- Dihydroergotamine (DHE)
- Can be effective in patients who have failed triptan therapy 3, 4
- Available as nasal spray or injectable formulations
- Contraindicated in patients with cardiovascular disease, uncontrolled hypertension, and within 24 hours of triptan use 3
- In one study, 47% of triptan-refractory patients had partial to complete response to DHE nasal spray 4
Important Considerations and Cautions
Medication Overuse Risk
- Limit acute medication use to prevent medication overuse headache:
- NSAIDs ≤15 days/month
- Triptans/gepants/ditans ≤10 days/month 2
Cardiovascular Safety
- DHE is contraindicated in patients with:
- Ischemic heart disease
- Uncontrolled hypertension
- Peripheral arterial disease
- Recent use of triptans (within 24 hours) 3
Driving Impairment
- Patients taking lasmiditan should not drive or operate machinery for at least 8 hours after intake 1
Complementary Approaches
- Regular lifestyle modifications (sleep schedule, meal times, hydration)
- Stress management techniques
- Magnesium supplements (400-600mg daily)
- Riboflavin supplements (400mg daily)
- Coenzyme Q10 supplements 2
By following this stepped approach to migraine management after triptan failure, patients can achieve better control of their migraine attacks and improved quality of life.