Triptans for Migraine Treatment
Triptans should be used as second-line therapy for moderate to severe migraines or mild to moderate migraines unresponsive to NSAIDs, with oral sumatriptan 50-100mg, rizatriptan 10mg, or zolmitriptan 2.5-5mg as the preferred initial choices, taken early in the attack when headache is still mild. 1
Treatment Algorithm
When to Use Triptans
Reserve triptans for patients with moderate to severe migraines or those with mild to moderate migraines that fail to respond to first-line NSAIDs (aspirin, ibuprofen, naproxen, or diclofenac) 1
Use triptans as second-line therapy after over-the-counter analgesics provide inadequate relief 1
Specific Dosing Recommendations
Oral Formulations (Standard First Choice):
- Sumatriptan: 25-100mg orally every 2 hours; maximum 200mg per day 1
- Rizatriptan: 5-20mg orally every 2 hours; maximum 30mg per day (reaches peak concentration in 60-90 minutes, faster than most other triptans) 1
- Zolmitriptan: 1.25-5mg initially; may repeat after 2 hours; maximum 10mg per 24 hours 2
- Eletriptan: 20-40mg initially; may repeat after 2 hours; maximum 80mg per day 3
- Naratriptan: 1.0-2.5mg orally every 4 hours; maximum 5mg per day (longest half-life, may reduce recurrence) 1
Non-Oral Routes (For Rapid Relief or When Nausea/Vomiting Present):
- Subcutaneous sumatriptan: 6mg SC, may repeat in 1 hour; maximum 12mg per 24 hours (reaches peak in 15 minutes, 70-82% effective—fastest and most effective route) 1
- Intranasal sumatriptan: 5-10mg (one to two sprays) in one nostril; may repeat after 2 hours; maximum 40mg per day 1
- Orally disintegrating tablets: Rizatriptan MLT or zolmitriptan for patients who cannot swallow pills or prefer not to use liquids 1, 4
Critical Timing Principles
Administer triptans early in the attack when headache is still mild for maximum effectiveness 1
Do NOT use triptans during the aura phase—no evidence supports this approach 1
If headache recurs within 8-12 hours, a second dose may be administered at the specified interval for each medication 1
Limit acute treatment to no more than twice per week to prevent medication-overuse headache 1
Trial-and-Error Strategy
Trial each triptan for 2-3 headache episodes before abandoning that medication 1
If one triptan fails, try a different triptan—non-responders to one may benefit from another 1
Match drug characteristics to patient needs: Consider onset speed, duration of action, and route of administration based on attack characteristics 1
Managing Recurrence
Upon relapse (return of symptoms within 48 hours), patients may repeat the triptan dose or combine with fast-acting NSAIDs (naproxen sodium, ibuprofen lysine, or diclofenac potassium) 1
Naratriptan may have lower recurrence rates due to its longer half-life, though evidence is speculative 1
Absolute Contraindications
Do not prescribe triptans in patients with: 1
- Ischemic vascular conditions or coronary artery disease
- Vasospastic coronary disease
- Uncontrolled hypertension
- Hemiplegic or basilar migraine
- Recent use (within 24 hours) of ergotamine derivatives or another triptan
- Concurrent MAOI use
Special Populations
Hepatic impairment: Use zolmitriptan 1.25mg (half of 2.5mg tablet); maximum 5mg per day in severe hepatic impairment 2
Cimetidine co-administration: Limit zolmitriptan to maximum 2.5mg single dose, not exceeding 5mg per 24 hours 2
Common Pitfalls to Avoid
Avoid using triptans too late in the attack—efficacy decreases significantly once central sensitization develops 4
Do not combine triptans with ergotamine derivatives within 24 hours due to additive vasoconstrictive effects 1
Recognize that subcutaneous sumatriptan has the highest therapeutic gain (51%) compared to oral formulations (29-37%), making it the best choice when rapid, reliable relief is essential 5
Consider non-oral routes when nausea/vomiting are prominent features (>90% of migraine patients experience nausea) 1, 4