What is the preferred treatment between triptans (sumatriptan) and Cafergot (ergotamine and caffeine) for a patient with recurrent migraine headaches?

Triptans Are Superior to Cafergot for Migraine Treatment

Triptans should be used instead of Cafergot (ergotamine plus caffeine) for acute migraine treatment, as they demonstrate significantly higher efficacy, faster onset of action, better tolerability, and lower risk of serious adverse events. 1, 2

Evidence Supporting Triptan Superiority

Efficacy Comparison

• Triptans achieve headache response (reduction from moderate-to-severe to mild or no pain) in 54-68% of patients at 2 hours, compared to only 33% with Cafergot. 2

• Complete pain freedom at 2 hours occurs in 28-38% of triptan-treated patients versus only 10% with Cafergot. 2

• Oral sumatriptan 100 mg demonstrates superior efficacy to Cafergot (2 mg ergotamine plus 200 mg caffeine) in controlled trials, with response rates of 50-67% at 2 hours. 3

• Subcutaneous sumatriptan provides even higher efficacy (70-84% at 1 hour, 81-87% at 2 hours) for patients requiring rapid relief or those with significant nausea/vomiting. 3

Speed of Onset

• Triptans provide significantly faster headache response at 1 hour (29-39%) compared to Cafergot (13%), allowing patients to return to function more quickly. 2

• Subcutaneous sumatriptan achieves peak blood concentrations in approximately 15 minutes, the fastest of any migraine-specific medication. 1

Associated Symptom Relief

• Triptans are significantly more effective than Cafergot in reducing nausea (p < 0.0001), photophobia (p < 0.002), phonophobia (p < 0.003), and functional impairment (p ≤ 0.001) at 2 hours. 2

Safety and Tolerability Profile

• Cafergot carries substantial risks including myocardial infarction, myocardial or pleuropulmonary fibrosis, vasospastic ischemia, and ergot poisoning with chronic use. 4

• Triptans demonstrate generally mild and transient adverse events (nausea, warmth, malaise, injection site reactions for subcutaneous formulations), with serious cardiovascular events occurring only in rare isolated cases. 4, 5

• The American Academy of Family Physicians assigns Cafergot an efficacy rating of only 3 out of 4, while triptans receive the highest rating of 4. 4

Current Guideline Recommendations

• The American College of Physicians recommends triptans as first-line therapy for moderate to severe migraine attacks, with no current recommendation for Cafergot use. 1

• Dihydroergotamine (DHE), a different ergot derivative, has good evidence for efficacy and safety as monotherapy, but Cafergot specifically is not recommended in modern guidelines. 1

• Cafergot is contraindicated with concurrent triptan use, limiting treatment flexibility. 4

Practical Treatment Algorithm

For mild to moderate migraine:

• Start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg) as first-line. 1
• If NSAIDs fail after 2-3 episodes, escalate to triptans. 4

For moderate to severe migraine:

• Use triptans as first-line therapy (sumatriptan 50-100 mg, rizatriptan 10 mg, or eletriptan 40 mg orally). 1
• Consider combination triptan + NSAID for superior efficacy. 1

For severe migraine with nausea/vomiting:

• Use subcutaneous sumatriptan 6 mg or intranasal formulations for rapid relief. 4, 1

When to avoid triptans (and consider alternatives, NOT Cafergot):

• Ischemic heart disease, uncontrolled hypertension, or cerebrovascular disease: use gepants (ubrogepant, rimegepant) or ditans (lasmiditan) instead. 1, 6

Critical Pitfalls to Avoid

• Never use Cafergot and triptans within 24 hours of each other due to additive vasoconstrictive effects. 4

• Limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency. 1

• Do not abandon triptan therapy after a single failed attempt—if one triptan is ineffective, try a different triptan, as failure of one does not predict failure of others. 4, 1

• Cafergot has a maximum limit of 10 tablets per week, creating risk of chronic daily headaches and ergot poisoning with overuse. 4

Why Cafergot Is Obsolete

The significantly lower efficacy (33% vs 54-68% response rate), slower onset, inferior symptom control, and higher risk of serious adverse events make Cafergot an outdated choice when superior alternatives (triptans) are available. 2 Modern guidelines have effectively replaced Cafergot with triptans as the standard of care for moderate to severe migraine. 1