Triptans Are the Appropriate Choice for Breakthrough Migraine Treatment, Not Emgality
Emgality (galcanezumab) is a preventive medication, not indicated for acute breakthrough migraine treatment, while triptans are specifically designed for acute migraine attacks. This is a fundamental distinction in migraine pharmacotherapy that must be understood clearly.
Why This Comparison Is Inappropriate
- Emgality is a CGRP monoclonal antibody used exclusively for migraine prevention, administered monthly via subcutaneous injection to reduce the frequency of migraine attacks 1
- Triptans are acute abortive medications designed to stop migraine attacks once they have started, working through 5-HT1B/1D receptor agonism to provide rapid relief 2, 3
- These medications serve completely different therapeutic purposes and are not interchangeable or comparable for breakthrough treatment
The Correct Acute Treatment: Rizatriptan
For breakthrough migraine treatment, rizatriptan 10mg is the most effective oral triptan option, with the highest clinical effectiveness rating of 4 out of 4. 1, 4
Key Advantages of Rizatriptan:
- Achieves faster pain relief and higher rates of 2-hour pain-free status compared to other oral triptans including eletriptan 1, 4
- Therapeutic gain of 37% (percentage response for active minus placebo), superior to most other oral triptans 2
- Available as orally disintegrating wafers reaching peak concentration in 60-90 minutes, particularly useful for patients with significant nausea 1, 4
- Dosing: 5-20mg orally every 2 hours, maximum 30mg per day 1, 4
Alternative Triptan Options
When Rizatriptan Is Insufficient:
- Sumatriptan 6mg subcutaneous injection provides the highest therapeutic gain (51%) among all triptan formulations and should be used when oral triptans fail or when patients rapidly reach peak headache intensity or cannot tolerate oral medications due to vomiting 1, 2, 3
- Eletriptan 80mg demonstrates a therapeutic gain of 42%, higher than standard oral sumatriptan 100mg (32%) 2
Lower Efficacy Options:
- Frovatriptan 2.5mg has the lowest therapeutic gain (16%) but the longest half-life (26-30 hours), which may reduce recurrence rates 2
- Naratriptan 2.5mg shows lower therapeutic gain (22%) compared to other triptans 2
Critical Timing and Combination Strategies
- All triptans must be taken early in the attack while headache is still mild for maximum effectiveness 1
- Never use triptans during the aura phase—there is no evidence supporting this practice 1
- For patients with frequent relapses, combine triptans with fast-acting NSAIDs (naproxen sodium, ibuprofen lysine, or diclofenac potassium) simultaneously, which shows equal or better outcomes than standard dose triptans alone 1
Important Safety Considerations
Absolute Contraindications for All Triptans:
- Ischemic vascular conditions
- Vasospastic coronary disease
- Uncontrolled hypertension
- Significant cardiovascular disease 1, 4
Additional Rizatriptan-Specific Contraindications:
- Ergot-type medications
- SSRIs, other triptans, MAOIs
- Propranolol, cimetidine
- Coronary artery disease 4
Common Pitfalls to Avoid
- If one triptan fails, trial another triptan before abandoning the class—different triptans may still provide relief due to pharmacological differences 1
- Repeating triptan treatment for relapse increases risk of medication overuse headache—counsel patients on appropriate frequency 1
- Headache recurrence occurs in 30-40% of patients within 24 hours after initial successful response; a second dose can be effective but increases overuse risk 2, 5
Clinical Algorithm for Breakthrough Migraine
- First-line: Rizatriptan 10mg orally at onset of mild headache 1, 4
- If nausea is prominent: Rizatriptan orally disintegrating wafer 1, 4
- If oral route fails or vomiting present: Sumatriptan 6mg subcutaneous 1, 3
- If frequent relapses: Add fast-acting NSAID simultaneously with triptan 1
- If first triptan ineffective: Trial different triptan before abandoning class 1