detailed information about triptans in migraine and second line treatments

Last reviewed 01/2018

  • triptans work by selectively stimulating 5-hydroxytriptamine 1 (5HT1) receptors in the brain
  • triptans are indicated for the treatment of attacks unresponsive to adequate doses of analgesics with an anti-emetic, especially if migraine occurs despite optimal prophylaxis, or too infrequently for this to be considered (1)

Prescribe the standard starting dose of oral sumatriptan (50 mg):

  • sumatriptan is the longest established triptan, and consequently has the most clinical experience attached to it. As a consequence it is often used as
  • the higher dose of sumatriptan (100 mg) offers little advantage over 50 mg for most people

When considering the response to treatment with oral sumatriptan 50mg (2):

  • sumatriptan 100 mg may prove more effective, but is also associated with more adverse effects
  • zolmitriptan 2.5 mg is as effective as sumatriptan and well tolerated
  • rizatriptan 10 mg is more effective than sumatriptan 100 mg and provides better sustained pain relief
  • eletriptan 40 mg is more effective than sumatriptan 100 mg. If this is well tolerated but is not fully effective, the 80 mg dose may be beneficial and also provides greater sustained pain relief
  • almotriptan 12.5 mg is as effective at relieving pain as sumatriptan 100 mg, and more effective at giving sustained pain relief. It also has fewer associated adverse effects
  • naratriptan 2.5 mg is less effective than sumatriptan 100 mg but, has significantly less adverse effects and may be better tolerated
  • frovatriptan 2.5 mg is less effective than sumatriptan 100 mg, but has less adverse effects

    Notes (2):

    • unlike symptomatic therapy, triptans should not be taken too early. There is increasing evidence of greater efficacy when taken whilst pain is still mild, but triptans appear to be ineffective if administered before the headache has developed (eg, during aura)
    • all triptans are associated with return of symptoms within 48 hours in 20-50% of patients who have initially responded (relapse). This is a troublesome limitation
    • when triptans are taken orally, concomitant administration of a prokinetic anti-emetic, metoclopramide or domperidone, is suggested on theoretical grounds: there is limited formal evidence to support their use
    • different formulations may also be considered if a rapid response is required or triptan effectiveness is limited by nausea and vomiting. Sumatriptan is the only drug available as a subcutaneous injection
    • ergotamine has largely been superseded by the 5HT1 agonists
      • ergotamine tartrate 1-2mg, in clinical trials in which it has been used as a comparator, has shown significantly lower relapse rates which may be due to its prolonged duration of action
      • toxicity and misuse potential are greater risks with ergotamine than with triptans
      • has very poor bioavailability and is better taken rectally
      • should not be taken concomitantly with any triptan, but is probably safe after 12 hours
      • NICE however advise " Do not offer ergots or opioids for the acute treatment of migraine"
    • dexamethasone in acute migraine
      • when added to standard abortive migraine therapy, single dose parenteral dexamethasone is associated with a 26% relative reduction in recurrent headache (NNT=9) occurring within 72 hours
      • a meta-analysis concluded that adding dexamethasone to standard therapy reduces short-term relapse of migraine (4)