Best Triptan for Treating Migraines
There is no single "best" triptan for all patients, but sumatriptan remains the gold standard with the most evidence, while rizatriptan, eletriptan, and almotriptan are considered fast-acting alternatives with comparable efficacy. 1
Triptan Selection Algorithm
First-Line Options:
- Sumatriptan 50-100mg oral: Most extensively studied triptan with proven efficacy 1, 2
- Rizatriptan 10mg: Faster onset of action compared to sumatriptan 3
- Eletriptan 40mg: Comparable efficacy to sumatriptan 100mg 3
- Almotriptan 12.5mg: Good balance of efficacy and tolerability 1, 4
Special Situations:
- For severe attacks or significant nausea/vomiting: Sumatriptan 6mg subcutaneous (highest efficacy with therapeutic gain of 51%) 1, 3
- For patients with slower onset migraines: Naratriptan 2.5mg or frovatriptan 2.5mg (longer half-lives) 3
- For patients who experience recurrence: Consider frovatriptan (26-30 hour half-life) or naratriptan which tends to have less recurrence 3
Efficacy Considerations
Triptans vary slightly in their efficacy profiles:
- Subcutaneous sumatriptan has the highest efficacy rate (70-80% relief within 1 hour) 5
- Oral triptans typically provide relief in 50-73% of patients within 2 hours 6
- Fast-acting triptans include rizatriptan 10mg, eletriptan 40mg, almotriptan 12.5mg, and zolmitriptan 2.5-5mg 4
- Therapeutic gain (percentage response over placebo) varies: sumatriptan 100mg (32%), rizatriptan 10mg (37%), eletriptan 40mg (37%), naratriptan 2.5mg (22%), frovatriptan 2.5mg (16%) 3
Safety and Tolerability
All triptans share similar contraindications:
- History of coronary artery disease or vasospasm
- Wolff-Parkinson-White syndrome
- History of stroke or TIA
- Peripheral vascular disease
- Uncontrolled hypertension
- Recent use of another triptan or ergotamine (within 24 hours)
- Recent use of MAO inhibitors (within 2 weeks) 7
Common adverse effects include:
- Paresthesia, warm/cold sensation
- Chest pain/tightness/pressure
- Neck/throat/jaw pain/tightness
- Dizziness and fatigue 7, 8
Important Clinical Considerations
Timing: Triptans are most effective when taken early in an attack while pain is still mild 9
Recurrence: Approximately 30-40% of patients experience headache recurrence within 24 hours after initial relief 3, 5
Medication overuse: Limit triptan use to no more than 9 days per month to prevent medication overuse headache 1
Failed response: If one triptan fails, another may still be effective 9
Combination therapy: Consider combining triptans with NSAIDs for enhanced efficacy and to prevent recurrence 9, 1
Third-Line Options
If all triptans fail or are contraindicated, consider:
The selection of the optimal triptan should be based on the patient's migraine characteristics, comorbidities, and previous treatment responses, but sumatriptan remains the most well-studied option with proven efficacy across multiple formulations.