Triptans Are Safe and Appropriate for Migraine with Aura
Yes, triptans including sumatriptan are safe and effective for treating migraine with aura when taken during the headache phase, but should not be taken during the aura itself. 1, 2
Key Treatment Principles
Triptans are FDA-approved and guideline-recommended as second-line therapy for moderate to severe migraine attacks, regardless of whether aura is present or absent. 2 The FDA label for sumatriptan explicitly states it is indicated for "acute treatment of migraine with or without aura in adults." 2
Timing Is Critical
Take triptans early in the headache phase when pain is still mild—NOT during the aura phase. 1 Multiple studies confirm that triptans are ineffective when administered during aura, though they remain safe. 3, 4
The aura phase represents cortical spreading depression, a neurological phenomenon that triptans cannot abort. 3 Wait until headache begins before taking the triptan. 1, 4
Early treatment during the headache phase (within 1 hour of pain onset) achieves pain-free rates of 79%, compared to only 21% when treatment is delayed 4 hours. 5
Recommended Approach for Migraine with Aura
First-Line Treatment
- Start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) for mild to moderate attacks. 6
Second-Line Treatment (When NSAIDs Fail)
Escalate to triptans for moderate to severe attacks or when NSAIDs provide inadequate relief after 2-3 episodes. 1, 6
Sumatriptan 50-100 mg orally is the standard starting dose. 2
If one triptan fails after 2-3 attacks, try a different triptan—failure of one does not predict failure of others. 1
Combination therapy (triptan + NSAID) is superior to either agent alone and represents the strongest evidence-based approach. 6
Alternative Routes for Severe Attacks
Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% pain-free at 2 hours) with onset within 15 minutes, particularly useful when nausea/vomiting is present or when rapid progression occurs. 1, 6
Intranasal formulations are appropriate when oral administration is compromised by nausea. 6
Critical Safety Considerations
Absolute Contraindications
Triptans are contraindicated in patients with: 2, 4
- Coronary artery disease or history of myocardial infarction
- Coronary artery vasospasm or Prinzmetal's angina
- Uncontrolled hypertension
- History of stroke or transient ischemic attack
- Peripheral vascular disease
- Hemiplegic or basilar migraine (these are different from typical migraine with aura)
Important Distinction
Migraine with typical visual aura is NOT a contraindication to triptan use—only hemiplegic and basilar migraine subtypes are contraindicated. 2 The presence of visual aura (zigzag lines, scotomas, etc.) does not increase cardiovascular risk and does not preclude triptan therapy. 2
Medication-Overuse Headache Prevention
Strictly limit all acute migraine medications (including triptans) to no more than 2 days per week (10 days per month) to prevent medication-overuse headache. 1, 6
If the patient requires acute treatment more than twice weekly, initiate preventive therapy immediately rather than increasing acute medication frequency. 6, 7
Common Pitfalls to Avoid
Do not withhold triptans from patients with typical migraine with aura based solely on the presence of aura—this is a common misconception. 2, 8
Do not instruct patients to take triptans during the aura phase, as this is ineffective and wastes medication. 1, 3, 4
Do not assume all "migraine with aura" is the same—hemiplegic and basilar subtypes are absolute contraindications, while typical visual aura is not. 2
If chest symptoms occur with triptan use, evaluate for coronary artery disease in high-risk patients, though most chest symptoms are not cardiac in origin. 2, 4