What is the recommended first-line therapy for migraine headaches using triptans (serotonin receptor agonists)?

First-Line Triptan Therapy for Migraine Headaches

For moderate to severe migraine attacks, triptans (serotonin receptor agonists) are recommended as first-line therapy, while NSAIDs are recommended as first-line for mild to moderate migraine attacks. 1, 2

Treatment Algorithm

First-Line Options

• For mild to moderate migraine attacks:

  • NSAIDs (aspirin, ibuprofen, naproxen sodium, diclofenac potassium) 2
  • Combination of acetaminophen-aspirin-caffeine 2

• For moderate to severe migraine attacks:

  • Triptans (serotonin 5-HT1B/1D receptor agonists) 2, 1
    • Oral triptans with proven efficacy: sumatriptan, rizatriptan, zolmitriptan, naratriptan 2
    • Subcutaneous sumatriptan has the fastest onset of action (approximately 15 minutes) 2, 3
    • Oral rizatriptan reaches peak concentration faster than other oral triptans (60-90 minutes vs. 2-3 hours) 2, 3

Triptan Selection Considerations

• Route of administration:

  • Use non-oral routes (subcutaneous, intranasal) when nausea/vomiting are prominent 2
  • Subcutaneous sumatriptan is recommended for patients who rapidly reach peak headache intensity 2, 4
  • Rizatriptan (Maxalt MLT) offers an absorbable wafer option 2

• Onset of action:

  • Subcutaneous sumatriptan: fastest onset (15 minutes) 2, 3
  • Oral rizatriptan: fastest oral onset (60-90 minutes) 2, 3
  • Oral naratriptan: slower onset but longer half-life, potentially fewer recurrence headaches 2, 3

• Efficacy considerations:

  • Triptans are most effective when taken early in an attack while pain is still mild 2
  • Do not use triptans during the aura phase of a migraine attack 2
  • If one triptan is ineffective, try a different triptan before abandoning this class of medication 2

Important Contraindications and Precautions

• Contraindications for triptans: 5, 6

  • History of coronary artery disease or vasospasm
  • Wolff-Parkinson-White syndrome or other cardiac conduction disorders
  • History of stroke, TIA, or hemiplegic/basilar migraine
  • Peripheral vascular disease
  • Uncontrolled hypertension
  • Use within 24 hours of another triptan or ergotamine-containing medication
  • Use within 2 weeks of MAO inhibitors
  • Severe hepatic impairment

• Common adverse effects: 5, 6

  • Paresthesia, warm/cold sensations
  • Chest/throat/neck/jaw pain or pressure (typically non-cardiac)
  • Dizziness, fatigue

Clinical Pearls and Pitfalls

• Medication overuse headache:

  • Limit acute treatments to no more than twice weekly to prevent medication overuse headache 2, 1
  • Overuse can lead to exacerbation of headache frequency and intensity 6

• Recurrence management:

  • Headache may recur within 48 hours in 21-57% of patients 2, 4
  • Upon recurrence, patients can repeat triptan treatment or combine with fast-acting NSAIDs 2
  • Naratriptan has a tendency toward less recurrence due to longer half-life 3

• Treatment failure:

  • Try a triptan for 2-3 headache episodes before abandoning that specific medication 2
  • If one triptan fails, try another before abandoning the entire class 2, 7
  • For patients with triptan failure, consider DHE nasal spray as an alternative 2

• Monitoring considerations:

  • The Headache Impact Test (HIT-6) score may help identify patients at risk for triptan discontinuation 7
  • Negative response to initial triptan treatment and high HIT-6 scores are associated with triptan discontinuation 7

Remember that triptans are not preventive medications and should only be used for acute treatment of migraine attacks 5, 8.