Best Triptans for Migraine
Primary Recommendation
Rizatriptan 10 mg is the best first-line triptan for acute migraine treatment, demonstrating superior efficacy with the fastest pain relief and highest 2-hour pain-free rates among oral triptans. 1, 2
Evidence-Based Triptan Selection
First-Line Choice: Rizatriptan 10 mg
- Rizatriptan 10 mg provides the most favorable outcomes with a clinical effectiveness rating of 4 out of 4 (highest possible), reaching peak concentration in 60-90 minutes—the fastest among oral triptans 1, 2
- Standard dosing is 10 mg orally at migraine onset, with the option to repeat after 2 hours if needed, up to a maximum of 30 mg per day 1, 2
- Available as orally disintegrating wafers for patients with significant nausea, eliminating the need for water 1, 2
Second-Line Choice: Eletriptan 80 mg
- Eletriptan 80 mg demonstrates superior efficacy outcomes compared to other oral triptans, though slightly less effective than rizatriptan 1
- Consider when rizatriptan is not tolerated or provides inadequate response 1
Alternative Oral Triptans
The American College of Physicians states that any triptan can be used as first-line treatment since all have well-documented effectiveness, with choice based on route of administration and cost 3
Available options include:
- Sumatriptan 50-100 mg (most studied, generic available) 3, 4
- Zolmitriptan 2.5-5 mg 3
- Naratriptan (longest half-life, may decrease recurrence) 3
- Almotriptan 3
- Frovatriptan 3
Critical Timing Principles
Triptans must be taken early in the attack when headache is still mild for maximum effectiveness—treating during mild pain phase gives significantly better outcomes than treating moderate or severe pain 1, 5
Do NOT use triptans during the aura phase, as there is no evidence supporting efficacy at this stage 1, 6
Combination Therapy for Enhanced Efficacy
Add an NSAID (naproxen 500 mg or ibuprofen 400-800 mg) to the triptan for superior efficacy—this combination is better than either agent alone 3
When NSAIDs are contraindicated, combine the triptan with acetaminophen 1000 mg 3
Trial-and-Error Approach
If one triptan fails, try a different triptan for 2-3 headache episodes before abandoning that medication, as individual response varies significantly and failure of one does not predict failure of others 1
Special Situations Requiring Non-Oral Routes
For Severe Nausea/Vomiting or Rapid Peak Intensity:
Sumatriptan 6 mg subcutaneous injection is the preferred option, providing the highest efficacy with 70-82% pain relief within 15 minutes and 59% pain-free at 2 hours 1, 4
For Patients Unable to Swallow:
- Intranasal sumatriptan 5-20 mg 1
- Rizatriptan orally disintegrating wafers 1, 2
- Zolmitriptan orally disintegrating tablets 7
Absolute Contraindications
Triptans are contraindicated in patients with: 1, 2, 4
- History of coronary artery disease or coronary vasospasm
- Uncontrolled hypertension
- Ischemic vascular conditions or vasospastic coronary disease
- Recent use (within 24 hours) of another triptan or ergotamine-containing medication
- Concurrent or recent use (past 2 weeks) of MAO-A inhibitors
- History of stroke or transient ischemic attack
Critical Frequency Limitation
Limit triptan use to no more than 10 days per month (approximately 2 days per week) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 3, 1
If requiring acute treatment more frequently, initiate preventive therapy immediately rather than increasing triptan frequency 3, 1
Managing Headache Recurrence
Approximately 40% of patients experience headache recurrence within 24 hours after initial response 6, 8
Relapses can be treated by repeating the triptan dose (minimum 2 hours after first dose) or combining with fast-acting NSAIDs 1
Medications to Avoid
Do NOT use opioids or butalbital-containing compounds for acute migraine treatment—they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time 3