What are the recommended triptans (triptan) for migraine treatment?

Recommended Triptans for Migraine Treatment

For acute migraine treatment, triptans are recommended as second-line therapy after NSAIDs, with sumatriptan, rizatriptan, and zolmitriptan being the most effective options based on current evidence. 1

Stepped Care Approach to Migraine Treatment

• First-line treatment: NSAIDs with proven efficacy (acetylsalicylic acid, ibuprofen, diclofenac potassium) 2
• Second-line treatment: Triptans when NSAIDs provide inadequate relief 2, 1
• Third-line treatment: Gepants (ubrogepant, rimegepant) when triptans fail or are contraindicated 2, 1

Recommended Triptans and Their Characteristics

Most Effective Triptans

• Sumatriptan: Available in multiple formulations (oral, subcutaneous injection, intranasal) 2, 3

  • Subcutaneous injection reaches peak concentration fastest (15 minutes) and is effective in 70-82% of patients 2
  • Recommended for patients who rapidly reach peak headache intensity or cannot take oral triptans due to vomiting 2
  • Dosage: 25mg, 50mg, or 100mg orally; maximum 200mg in 24 hours 3

• Rizatriptan: Reaches peak concentration in 60-90 minutes 2

  • Available as standard tablets and orally disintegrating tablets (ODT) 4
  • Among the most favorable outcomes in comparative studies 5

• Zolmitriptan: Available as standard tablets and orally disintegrating tablets 4

  • Demonstrated good efficacy in comparative studies 5

• Eletriptan: Shows consistent and significant clinical efficacy 6

  • Dosage: 20-40mg, with 40mg being more effective; maximum 80mg daily 7
  • Favorable clinical response in comparative studies 5

Other Available Triptans

• Naratriptan: Has the longest half-life among triptans, which may decrease chance of recurrence headaches 2, 8
• Almotriptan: Good tolerability profile 9
• Frovatriptan: Extended half-life (26-30 hours) 8

Clinical Application Guidelines

• Triptans are most effective when taken early in an attack while headache is still mild 2, 1

• If one triptan is ineffective, try another triptan or a different formulation 2, 9

• For patients experiencing nausea/vomiting during attacks, consider non-oral routes:

  • Sumatriptan subcutaneous injection or nasal spray 2, 4
  • Rizatriptan or zolmitriptan orally disintegrating tablets 4

• Upon relapse (return of symptoms within 48 hours), patients can:

  • Repeat triptan treatment
  • Combine triptan with fast-acting NSAIDs 2
  • Be aware that repeated treatment increases risk of medication overuse headache 2

Important Contraindications and Precautions

• Triptans should not be used in patients with:

  • History of coronary artery disease or coronary vasospasm 3
  • Uncontrolled hypertension 2, 3
  • Basilar or hemiplegic migraine 2, 3
  • Recent (within 24 hours) use of another triptan or ergotamine-containing medication 3
  • Concurrent or recent (past 2 weeks) use of MAO-A inhibitors 3

• To prevent medication overuse headache, limit acute treatment to no more than twice a week 2

Practical Algorithm for Triptan Selection

1. Start with sumatriptan 50mg or 100mg as initial triptan trial 2, 3
2. If ineffective or poorly tolerated, switch to rizatriptan or eletriptan 5
3. For patients with nausea/vomiting, use sumatriptan injection/nasal spray or orally disintegrating tablets 2, 4
4. For patients concerned about recurrence, consider naratriptan with its longer half-life 2, 8
5. For patients with cardiovascular risk factors (but without coronary artery disease), eletriptan may be preferred 6

• Remember to try a medication for 2-3 headache episodes before abandoning that line of therapy 2
• If all triptans fail after adequate trials, consider third-line gepants 2, 1