What are the recommended triptans (serotonin receptor agonists) and their dosages for migraine treatment?

Triptans for Acute Migraine Treatment: Agents and Dosing

For acute migraine treatment, triptans are second-line therapy when over-the-counter NSAIDs fail, with oral sumatriptan 50-100 mg, rizatriptan 10 mg, or eletriptan 40 mg being the most effective first-choice triptans based on efficacy, speed of onset, and consistency. 1, 2

Treatment Algorithm

First-Line: NSAIDs

• Start with acetylsalicylic acid, ibuprofen, or diclofenac potassium before escalating to triptans 1

Second-Line: Triptans (When NSAIDs Inadequate)

Highest Efficacy Oral Triptans:

• Rizatriptan 10 mg: Provides the greatest early efficacy among oral triptans with best consistency (67% response in ≥2 of 3 attacks) 3, 4, 2

  • Can repeat every 2 hours if needed 3
  • Maximum daily dose: 30 mg 4
  • Available as orally disintegrating tablet (Maxalt MLT) for patients with nausea/vomiting 3, 5

• Eletriptan 40-80 mg: Superior efficacy to sumatriptan 100 mg at higher doses 6, 2, 7

  • 40 mg dose recommended initially 6
  • Can repeat after 2 hours if needed 6
  • Maximum daily dose: 80 mg 6
  • 80 mg dose shows highest efficacy but more adverse effects 2, 7

• Sumatriptan: Most widely prescribed with longest clinical experience 8, 2

  • Oral: 25 mg, 50 mg, or 100 mg 8
    • 100 mg most effective oral dose (59% 2-hour response) 9, 2
    • Can repeat after 2 hours if partial response 8
    • Maximum daily dose: 200 mg 8
  • Subcutaneous 6 mg: Most rapid onset and greatest efficacy of all triptans, useful when oral route fails or patient reaches peak intensity rapidly 1, 10, 11
    • Can repeat after 1 hour 10
    • Maximum daily dose: 12 mg 10
  • Intranasal 5-10 mg: Rapid absorption, significant pain-free rates at 15 minutes 10, 5
    • Can repeat after 2 hours 10
    • Maximum daily dose: 40 mg 10

Moderate Efficacy Options:

• Almotriptan 12.5 mg: Similar 2-hour efficacy to sumatriptan 100 mg but better sustained pain-free response and fewer adverse effects 12, 2

  • Starting dose 6.25-12.5 mg 12
  • Can repeat after 2 hours 12
  • Maximum daily dose: 25 mg 12
  • Reduce to 6.25 mg maximum 12.5 mg/day in hepatic or severe renal impairment 12

• Zolmitriptan 2.5-5 mg: Very similar results to sumatriptan 100 mg 2

  • Available as orally disintegrating tablet and intranasal spray 5

Lower Efficacy, Better Tolerated:

• Naratriptan 2.5 mg: Slower onset, high tolerability, long half-life 11, 2

  • May have role in prolonged attacks 11

• Frovatriptan: Substantially lower efficacy but longest half-life 2

  • Consider for prolonged migraine attacks 11

Critical Timing and Strategy

• Take triptans early when headache is still mild for maximum effectiveness 1
• Do NOT take during aura phase—no evidence of benefit 1
• Trial 2-3 migraine episodes before abandoning a specific triptan 3, 10
• If one triptan fails, try another—individual response varies significantly 1, 3, 10, 2

Combination Therapy for Inadequate Response

• Combine triptan with fast-acting NSAID (naproxen sodium, ibuprofen lysine, or diclofenac potassium) if monotherapy insufficient 1, 10
• This reduces relapse rates (return of symptoms within 48 hours) 1

Common Pitfalls

Medication Overuse Headache

• Repeating triptan doses increases risk of medication overuse headache (MOH) 1, 3
• Limit to treating <4 migraines per 30-day period when possible 8, 6

Contraindications (All Triptans)

• Coronary artery disease or vasospasm 3, 10, 8
• Hemiplegic or basilar migraine 3, 10, 8
• Concurrent use with ergotamine derivatives 3, 10, 8
• Use within 24 hours of another triptan 3, 10, 8
• MAOIs (within 2 weeks) 3, 10, 8
• Uncontrolled hypertension 8
• Pregnancy 3, 10, 8
• Severe hepatic impairment (sumatriptan) 8

Common Adverse Effects

• Chest pressure/heaviness, throat tightness 3, 10, 2
• Paresthesia, warm/cold sensations 8, 2
• Generally NOT associated with myocardial ischemia, but evaluate high-risk patients 8
• Subcutaneous sumatriptan causes injection site reactions in ~30% 10, 11

Special Formulations for Nausea/Vomiting

• Use orally disintegrating tablets (rizatriptan MLT, zolmitriptan) when nausea/vomiting present 3, 5
• Consider intranasal or subcutaneous routes when oral absorption unreliable 10, 5
• Add antiemetic for severe nausea/vomiting 10