What is the recommended treatment with triptan (triptans) for a patient with migraines or severe headaches, considering their medical history and potential contraindications?

Triptan Treatment for Migraine Headaches

Triptans are first-line therapy for moderate to severe migraine attacks, with oral sumatriptan 100 mg, rizatriptan 10 mg, naratriptan, and zolmitriptan all demonstrating strong efficacy. 1

First-Line Triptan Selection

• For moderate to severe migraine, start with oral sumatriptan 100 mg or rizatriptan 10 mg at headache onset, ideally when pain is still mild for maximum effectiveness. 1, 2
• Sumatriptan 100 mg provides pain-free response in approximately 1 in 5 patients at 2 hours (NNT 5.1), with headache relief in approximately 1 in 3 patients (NNT 3.4). 3
• Rizatriptan 10 mg reaches peak concentration in 60-90 minutes, making it the fastest oral triptan available. 1
• Combine triptan with NSAID (naproxen 500 mg or ibuprofen 400-800 mg) for superior efficacy compared to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours. 1

Route Selection Based on Clinical Presentation

• For patients with severe nausea, vomiting, or rapid progression to peak intensity, use subcutaneous sumatriptan 6 mg, which provides the highest efficacy with 70-82% achieving relief within 15 minutes and 59% achieving complete pain-free response by 2 hours. 1, 4
• Intranasal sumatriptan (5-20 mg) or other nasal spray triptans are particularly useful when significant nausea or vomiting is present but subcutaneous route is not preferred. 1
• Oral formulations remain most user-friendly despite erratic absorption during migraine attacks due to gastric stasis. 5

Critical Contraindications (Absolute)

Before prescribing any triptan, perform cardiovascular evaluation in triptan-naive patients with multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD). 6

• Ischemic heart disease or previous myocardial infarction - triptans cause coronary artery vasoconstriction and can precipitate myocardial ischemia. 6
• Prinzmetal's angina (coronary artery vasospasm) - triptans can trigger vasospastic angina even without known CAD. 6
• Uncontrolled hypertension - triptans can cause significant blood pressure elevation including hypertensive crisis. 6
• History of stroke or transient ischemic attack - cerebral hemorrhage, subarachnoid hemorrhage, and stroke have occurred with triptan use. 6
• Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders - life-threatening arrhythmias including ventricular tachycardia and ventricular fibrillation have been reported. 6
• Peripheral vascular disease - triptans may cause non-coronary vasospastic reactions including peripheral vascular ischemia and Raynaud's syndrome. 6

Medication Frequency Limits to Prevent Medication-Overuse Headache

Strictly limit all triptan use to no more than 2 days per week (maximum 10 days per month) to prevent medication-overuse headache. 1, 6

• Overuse of triptans for 10 or more days per month leads to exacerbation of headache and may present as migraine-like daily headaches or marked increase in migraine frequency. 6
• If patient requires acute treatment more than twice weekly, initiate preventive therapy immediately (propranolol 80-240 mg/day, topiramate, or CGRP monoclonal antibodies). 1

Algorithm for Triptan Failure

If one triptan fails after 2-3 headache episodes, try a different triptan, as failure of one does not predict failure of others. 1

1. First alternative: Rizatriptan 10 mg (fastest oral triptan with peak at 60-90 minutes). 1
2. Second alternative: Eletriptan 40 mg or zolmitriptan 2.5-5 mg (reportedly more effective with fewer adverse reactions than sumatriptan). 1
3. Third alternative: Naratriptan (longest half-life, may decrease recurrence headaches). 1
4. Consider route change: Subcutaneous sumatriptan 6 mg if oral formulations fail, particularly for rapid progression or vomiting. 1
5. If all triptans fail after adequate trials, escalate to CGRP antagonists (ubrogepant 50-100 mg, rimegepant, or zavegepant). 1, 7

Managing Headache Recurrence

• Headache recurs in 21-57% of patients within 24-48 hours after initial triptan response, likely related to the short half-life (approximately 2 hours). 8, 4
• Most patients respond to a second dose of the same triptan for recurrent headache, but ensure total use does not exceed frequency limits. 8
• Consider adding NSAID to prevent relapse, which addresses the 40% of patients who experience symptom recurrence within 48 hours. 1

Special Monitoring Requirements

• For patients with multiple cardiovascular risk factors but negative cardiovascular evaluation, administer first dose in medically supervised setting and perform ECG immediately following administration. 6
• Consider periodic cardiovascular evaluation in intermittent long-term users with cardiovascular risk factors. 6
• Monitor blood pressure in all patients treated with triptans. 6

Common Adverse Events

• Sensations of tightness, pain, pressure, and heaviness in the precordium, throat, neck, and jaw occur commonly but are usually non-cardiac in origin; however, perform cardiac evaluation if patient is at high cardiac risk. 6
• Nausea, vomiting, malaise, and fatigue are most common with oral sumatriptan. 8
• Injection site reactions occur in 10-40% of patients receiving subcutaneous formulation. 8
• Minor adverse events occur commonly (NNH 7.1 for sumatriptan 100 mg vs placebo), but serious adverse events occur in only 0.14% of patients. 8, 3

Serotonin Syndrome Risk

Discontinue triptan immediately if serotonin syndrome is suspected, particularly during co-administration with SSRIs, SNRIs, TCAs, or MAO inhibitors. 6

• Symptoms include mental status changes (agitation, hallucinations, coma), autonomic instability (tachycardia, labile blood pressure, hyperthermia), neuromuscular aberrations (hyperreflexia, incoordination), and gastrointestinal symptoms (nausea, vomiting, diarrhea). 6
• Onset typically occurs within minutes to hours of receiving new or greater dose of serotonergic medication. 6