What is a recommended triptan (triptans) for migraine headache treatment?

Recommended Triptan for Migraine Headache

Rizatriptan 10mg is the recommended first-line triptan for acute migraine treatment, demonstrating superior efficacy with the highest consistency of response (67% response in ≥2 of 3 attacks) and faster pain relief compared to other oral triptans. 1, 2

Optimal Triptan Selection

Rizatriptan 10mg provides:

• Highest clinical effectiveness rating (4 out of 4) among oral triptans 3
• Superior 2-hour pain-free rates compared to other triptans 1
• Fastest onset with greatest early efficacy 2
• Best consistency across multiple attacks 2

Alternative high-efficacy option:

• Eletriptan 80mg shows comparable efficacy to rizatriptan with therapeutic gain of 42% versus 32% for standard sumatriptan 100mg 4
• However, rizatriptan remains preferred based on consistency data 1, 3

Dosing Protocol

Rizatriptan administration: 5, 3

• Initial dose: 5-20mg orally at headache onset
• May repeat after 2 hours if needed
• Maximum daily dose: 30mg per day

For patients with significant nausea:

• Use rizatriptan orally disintegrating wafers (MLT formulation) which reach peak concentration in 60-90 minutes 3, 2

Critical Timing Principles

Take triptans early when headache is still mild—this is essential for maximum effectiveness. 5, 2

• Do NOT use during aura phase—no evidence supports efficacy at this stage 5, 2
• Trial each triptan for 2-3 migraine episodes before abandoning that medication 2
• If one triptan fails after adequate trial, switching to a different triptan may still provide relief as individual response varies 5, 2

When to Use Alternative Formulations

Subcutaneous sumatriptan 6mg is preferred when: 2

• Patient has severe nausea/vomiting precluding oral absorption
• Patient rapidly reaches peak headache intensity
• All oral triptans have failed
• Most rapid onset (15 minutes) and greatest overall efficacy of all triptan formulations 2, 6

Intranasal sumatriptan 5-10mg: 2

• Rapid absorption with significant pain-free rates at 15 minutes
• Can repeat after 2 hours to maximum 40mg daily

Combination Therapy for Inadequate Response

If triptan monotherapy insufficient, combine with fast-acting NSAID: 5, 2

• Naproxen sodium, ibuprofen lysine, or diclofenac potassium
• Warning: Repeated dosing increases risk of medication overuse headache 5

Absolute Contraindications (All Triptans)

Do not prescribe triptans in patients with: 5, 3, 2, 7, 8

• Coronary artery disease or coronary vasospasm
• Uncontrolled hypertension
• History of stroke or transient ischemic attack
• Hemiplegic or basilar migraine
• Peripheral vascular disease
• Ischemic bowel disease
• Wolff-Parkinson-White syndrome or cardiac accessory pathway disorders
• Recent use (within 24 hours) of another triptan or ergotamine-containing medication
• Concurrent or recent (within 2 weeks) MAO-A inhibitor use

Rizatriptan-specific contraindications: 5, 3

• Concurrent use with propranolol
• Concurrent use with cimetidine

Common Pitfalls to Avoid

Medication overuse headache: 5

• Limit triptan use to avoid chronic daily headache
• Counsel patients that repeated dosing for recurrence increases MOH risk

Inadequate trial before switching: 2

• Patients must try a triptan for 2-3 separate migraine episodes before concluding it is ineffective
• Individual response varies significantly between triptans

Treating during aura: 5, 2

• No evidence supports triptan use during aura phase
• Wait until headache phase begins for optimal efficacy