What is the recommended treatment protocol for migraines using triptans (serotonin receptor agonists)?

Triptan Treatment Protocol for Migraines

Triptans should be used as second-line therapy in patients whose migraine attacks do not respond to NSAIDs, with specific oral options including naratriptan, rizatriptan, zolmitriptan, and sumatriptan. 1

Treatment Algorithm for Migraine Using Triptans

First-Line Treatment

• NSAIDs are the first-line treatment for most patients with migraine (aspirin, ibuprofen, naproxen sodium, or acetaminophen-aspirin-caffeine combination) 1
• Acetaminophen alone is ineffective for migraine treatment 1

Second-Line Treatment: Triptans

• Initiate triptans when NSAIDs fail to provide adequate relief 1
• Recommended triptans with good evidence for efficacy:
  • Oral naratriptan
  • Oral rizatriptan (most effective with highest clinical effectiveness rating) 2
  • Oral zolmitriptan
  • Oral and subcutaneous sumatriptan 1

Dosing Guidelines

• Sumatriptan:
  • Available doses: 25mg, 50mg, or 100mg orally 3
  • Maximum daily dose: 200mg in a 24-hour period 3
  • A second dose may be administered if migraine hasn't resolved after 2 hours or returns after transient improvement 3
  • Doses must be separated by at least 2 hours 3
• Rizatriptan:
  • Available in doses of 5-20mg orally every two hours 2
  • Maximum daily dose: 30mg 2
  • Available as orally disintegrating wafers for patients with significant nausea 2, 4

Route of Administration Selection

• Use non-oral routes when nausea or vomiting are significant components of migraine attacks 1
• Options include:
  • Subcutaneous sumatriptan 1
  • Intranasal formulations (sumatriptan, zolmitriptan) 1, 5
  • Orally disintegrating tablets (rizatriptan) for patients with nausea 2, 4

Important Contraindications and Precautions

Absolute Contraindications

• Uncontrolled hypertension 1, 3
• Basilar or hemiplegic migraine 1, 3
• Coronary artery disease or risk factors for heart disease 1, 3
• History of stroke, transient ischemic attack 3
• Peripheral vascular disease 3
• Ischemic bowel disease 3
• Use within 24 hours of another triptan or ergotamine-containing medication 3
• Concurrent or recent (past 2 weeks) use of MAO inhibitors 3
• Severe hepatic impairment 3

Dose Adjustments

• For patients with mild to moderate hepatic impairment, maximum single dose of sumatriptan should not exceed 50mg 3

Monitoring for Adverse Effects

• Common side effects include paresthesia, warm/cold sensation, chest pain/tightness/pressure, neck/throat/jaw pain/tightness/pressure, vertigo, and fatigue 3
• Monitor for medication overuse headache - limit use to no more than twice weekly 1, 4
• Watch for signs of serotonin syndrome, especially when combined with SSRIs 3

Triptan Selection Strategy

• Try a triptan for 2-3 migraine episodes before determining effectiveness 4
• If one triptan is ineffective, try a different triptan 4
• Rizatriptan 10mg has demonstrated superior efficacy with faster pain relief compared to other triptans 2
• Consider adding metoclopramide 10mg to sumatriptan for triptan-nonresponsive migraineurs 6

Special Considerations

• For patients with significant nausea, consider orally disintegrating tablets or non-oral routes 2, 4
• Triptans may be effective for cluster headaches in addition to migraines 7
• Consider preventive therapy if acute treatments are used more than twice weekly or if patient experiences two or more migraine attacks per month with disability lasting three or more days 1