Triptan Side Effects
Triptans are generally well tolerated with common benign side effects including chest pressure/heaviness, paresthesias, dizziness, and nausea, but carry rare serious cardiovascular risks that contraindicate their use in patients with ischemic vascular disease, uncontrolled hypertension, or significant cardiovascular disease. 1, 2
Common Side Effects (Generally Mild and Self-Limited)
Sensory Disturbances
- Chest pressure or heaviness (not indicative of cardiac ischemia in most cases) 1, 3, 2
- Paresthesias (tingling or numbness), particularly in fingers and toes 1, 3, 2
- Warmth or cold sensations throughout the body 1, 2
Neurological Effects
Gastrointestinal Effects
Other Common Effects
- Throat, neck, or jaw tightness/discomfort 1, 2, 4
- Injection site reactions (for subcutaneous sumatriptan) 1
- Malaise 1
Serious Adverse Events (Rare but Important)
Cardiovascular Events
- Coronary vasospasm leading to angina, myocardial infarction, ventricular arrhythmias 1
- Hypertension 1
- Cerebrovascular events including stroke 1
- Important context: Large epidemiological studies show no increased risk of stroke or MI in triptan users compared to non-users in real-world practice 5
Peripheral Vascular Events
- Raynaud's syndrome (changes in color or sensation in fingers and toes) 2
- Peripheral vascular ischemia with symptoms including leg cramping, pain, cold feeling, or color changes 2
- Gastrointestinal and colonic ischemia presenting as severe stomach pain, bloody diarrhea, or weight loss 2
Serotonin Syndrome
- Rare but potentially life-threatening when triptans are combined with SSRIs or SNRIs 2, 4, 6
- Symptoms include mental status changes (hallucinations, agitation), fast heartbeat, blood pressure changes, high body temperature, muscle rigidity, and seizures 2, 4
- Critical caveat: One large prospective study failed to document a single case, suggesting this risk may be overstated 6
Medication Overuse Headache
- Chronic use leads to worsening headaches and increased headache frequency 2
- Limit use to avoid this rebound phenomenon 1, 2
Drug-Specific Side Effect Profiles
Sumatriptan
- Most data available given longest market presence (since 1991) 6
- Injection form has highest rate of injection site reactions 1
- Nausea, warmth, vertigo, malaise, chest pressure 1
Rizatriptan
- Tachycardia, bradycardia, throat tightness 1
- Requires dose adjustment with propranolol (drug interaction) 1
Zolmitriptan
- Similar profile to other oral triptans 1
- Pain, pressure or tightness in neck/throat/jaw, tingling, drowsiness 4
Naratriptan
- Longest half-life may reduce recurrence headaches 1
- Dizziness, drowsiness, nausea, fatigue, paresthesias 1
Eletriptan
- Most complex pharmacokinetic profile due to CYP3A4 metabolism 7
- Requires caution with CYP3A4 inhibitors 7
- Favorable tolerability profile overall 7
Critical Safety Considerations
Absolute Contraindications
- Ischemic vascular conditions (coronary, cerebral, or peripheral) 1, 8, 3
- Vasospastic coronary disease 1
- Uncontrolled hypertension 1
- Hemiplegic or basilar migraine 1
- Recent MAOI use (within 14 days) 1, 4
- Concurrent ergotamine use (within 24 hours) 1
Important Drug Interactions
- SSRIs and SNRIs: Risk of serotonin syndrome 1, 2, 4
- Ergot derivatives: Additive vasospasm risk 1
- MAOIs: Contraindicated 1, 4
- Propranolol with rizatriptan: Requires dose reduction 1
- CYP3A4 inhibitors with eletriptan: Avoid potent inhibitors 7
Clinical Management Pearls
- If one triptan causes intolerable side effects, try a different triptan due to pharmacological differences between agents 3
- Maximum daily dosing must be respected: Sumatriptan 200mg oral/12mg subcutaneous, rizatriptan 30mg, zolmitriptan 10mg 1, 2, 4
- Overall safety profile is excellent with over 30 years of clinical experience and extensive postmarketing surveillance 6
- Seizures have occurred in patients with no prior seizure history 2