What is the appropriate initial treatment with triptans for a migraine patient?

Appropriate Initial Treatment with Triptans for Migraine

Triptans should be offered as second-line therapy when over-the-counter NSAIDs (aspirin, ibuprofen, or diclofenac) provide inadequate relief, with oral sumatriptan 50-100 mg, rizatriptan 10 mg, or eletriptan 40 mg being the most effective first-choice options. 1, 2

Stepped Care Approach to Triptan Initiation

When to Start Triptans

• Escalate to triptans after NSAIDs fail to provide adequate headache relief over 2-3 migraine episodes 1
• First-line treatment should always be acetylsalicylic acid, ibuprofen, or diclofenac potassium before considering triptans 1

Optimal Triptan Selection and Dosing

For oral therapy:

• Rizatriptan 10 mg provides the greatest early efficacy with best consistency (67% response in ≥2 of 3 attacks) 2
• Sumatriptan 50-100 mg achieves headache relief in 50-67% of patients at 2 hours, with NNT of 3.4 2, 3, 4
• Eletriptan 40 mg provides comparable efficacy to sumatriptan 100 mg 2

For non-oral routes when needed:

• Subcutaneous sumatriptan 6 mg has the most rapid onset (within 15 minutes) and greatest efficacy (70-82% response rate) among all triptans 2, 5, 4
• Use subcutaneous route when oral triptans fail, patient reaches peak intensity rapidly, or vomiting prevents oral administration 1
• Intranasal sumatriptan 5-20 mg provides significant pain-free rates at 15 minutes and can be repeated after 2 hours 2, 5

Critical Timing Strategy

• Take triptans early when headache is still mild for maximum effectiveness—this is the single most important factor for success 1, 2
• Do NOT take during aura phase—no evidence supports benefit during aura 1, 2
• Allow at least 2 hours between doses if initial dose fails 3
• Maximum daily dose: 200 mg for oral sumatriptan, 12 mg for subcutaneous, 40 mg for intranasal 5, 3

Trial Period and Switching Strategy

• Trial each triptan for 2-3 separate migraine episodes before determining effectiveness 2, 5
• If one triptan fails, try a different triptan—failure of one does not predict failure of others 1, 2
• Consider all available triptans (sumatriptan, rizatriptan, zolmitriptan, naratriptan, almotriptan, frovatriptan, eletriptan) as options 2

Combination Therapy for Enhanced Efficacy

• Combine triptan with fast-acting NSAID (naproxen sodium, ibuprofen lysine, or diclofenac potassium) if monotherapy insufficient 1, 2
• This combination is superior to either agent alone and should be considered before increasing triptan dose or frequency 2

Absolute Contraindications

Do not prescribe triptans in patients with:

• Coronary artery disease, previous myocardial infarction, or vasospasm 2, 5
• Hemiplegic or basilar migraine 2, 5
• Uncontrolled hypertension 2, 5
• Concurrent use with ergotamine derivatives or within 24 hours of another triptan 2, 5
• MAOI use within 2 weeks 2, 5
• Severe hepatic impairment (for sumatriptan, maximum 50 mg dose) 3

Critical Frequency Limitation

• Limit triptan use to no more than 10 days per month (approximately 2 days per week) to prevent medication-overuse headache 2, 5
• Warn patients that repeating treatment does not preclude further relapses and increases MOH risk 1
• If patient requires acute treatment more than twice weekly, initiate preventive therapy immediately 2

Special Formulations for Specific Situations

• Use orally disintegrating tablets (rizatriptan MLT, zolmitriptan) when nausea/vomiting present but patient can avoid liquids 2
• Consider intranasal or subcutaneous routes when oral absorption unreliable due to severe nausea/vomiting 2
• Add antiemetic (metoclopramide 10 mg or prochlorperazine) for severe nausea/vomiting 2

Common Prescribing Pitfalls to Avoid

• Never prescribe triptans for use during aura—wait until headache phase begins 1, 2
• Never allow patients to exceed frequency limits—this creates medication-overuse headache and worsens outcomes 2, 5
• Never abandon triptan therapy after single failed attempt—different triptans work for different patients 1, 2
• Never combine with ergotamine derivatives or use within 24 hours of each other 2, 5