What are the recommended doses and repeat limits for oral triptans used for acute treatment of migraine without aura?

Triptan Dosing Recommendations for Acute Migraine Treatment

For oral triptans in acute migraine, start with standard doses (e.g., sumatriptan 50-100 mg, rizatriptan 10 mg, zolmitriptan 2.5-5 mg, almotriptan 12.5 mg), taken early when headache is mild, and may repeat once after 2 hours if needed, but do not exceed 2 treatment days per week to avoid medication overuse headache. 1, 2, 3

Specific Dosing by Triptan

Sumatriptan

• Oral: 25-100 mg at onset; may repeat after 2 hours if needed; maximum 200 mg per 24 hours 1
• Subcutaneous: 6 mg; may repeat after 1 hour; maximum 12 mg per 24 hours 1
• Intranasal: 5-10 mg (one to two sprays) in one nostril; may repeat after 2 hours; maximum 40 mg per day 1
• Subcutaneous formulation reaches peak concentrations fastest (approximately 15 minutes) and is most effective for patients who rapidly reach peak intensity, experience severe vomiting, or have failed all oral triptans 1, 2

Zolmitriptan

• Oral tablets: Starting dose 1.25 mg or 2.5 mg; maximum single dose 5 mg 3
• May repeat after 2 hours if needed; maximum 10 mg in any 24-hour period 3
• The 5 mg dose offers additional benefits over 2.5 mg at early time points 4
• Hepatic impairment: Use 1.25 mg in moderate or severe hepatic dysfunction 3

Rizatriptan

• Oral: Standard dosing reaches peak concentration in 60-90 minutes, faster than most other triptans 1
• Available as absorbable wafer (Maxalt MLT) for patients with significant nausea/vomiting 1
• Rizatriptan 10 mg is among the fast-acting triptans with efficacy similar to sumatriptan 100 mg 5

Naratriptan

• Oral: 1.0-2.5 mg every 4 hours; maximum dosing per 24 hours as specified 1
• Has the longest half-life among triptans, which may decrease recurrence headaches 1

Other Triptans

• Almotriptan: 12.5 mg is the recommended dose 6, 5
• Eletriptan: 40 mg is among the fast-acting triptans 5
• Frovatriptan: Available but generally slower onset 5

Critical Timing Principles

Take triptans early in the attack when headache is still mild for maximum effectiveness. 1, 7, 8

• Pain-free responses and therapeutic gains increase significantly when triptans are taken during mild headache rather than waiting for moderate-to-severe pain 8, 6
• Do not take during the aura phase - no evidence supports efficacy during aura 1, 7
• For patients treating within 1 hour of onset, almotriptan 12.5 mg achieved 37.9% pain-free rates at 2 hours and 34.7% sustained pain-free rates 6

Repeat Dosing and Frequency Limits

Limit triptan use to no more than 2 days per week to prevent medication overuse headache. 2

• If headache recurs (typically within 8-12 hours), may repeat with a second dose 1
• Upon relapse, patients can repeat triptan treatment or combine with fast-acting NSAIDs 7
• Caution: Frequent use (more than 2 days per week) leads to medication overuse headache and daily headaches 2

Trial-and-Error Approach

If one triptan is ineffective, try a different triptan before abandoning this class. 1, 7

• Patients should trial a medication for 2-3 headache episodes before determining ineffectiveness 1
• Failure of one triptan does not predict failure of others due to pharmacological heterogeneity 1, 5
• Match drug characteristics (speed of onset, duration of action, formulation) with patient needs and usual headache duration 1

Adjunct Medications

For patients with nausea/vomiting, add prokinetic antiemetics:

• Domperidone or metoclopramide as useful oral adjuncts 1, 7

Absolute Contraindications

Do not prescribe triptans in patients with: 3

• Coronary artery disease or coronary vasospasm
• History of stroke, TIA, hemiplegic or basilar migraine
• Peripheral vascular disease or ischemic bowel disease
• Uncontrolled hypertension
• Recent use (within 24 hours) of another triptan or ergotamine-containing medication
• MAO-A inhibitor use in past 2 weeks
• Symptomatic Wolff-Parkinson-White syndrome

Common Pitfalls to Avoid

• Avoid oral ergot alkaloids, opioids, and barbiturates - these have questionable efficacy, considerable adverse effects, and risk of dependency 1, 7
• Do not use triptans as prophylactic therapy 3
• Verify local formulary availability before prescribing, as triptan availability varies significantly between countries 2
• Sumatriptan is typically the most widely available internationally due to generic formulations 2