Triptans for Migraine Treatment

I tell patients that triptans have "headache free" data for migraine treatment in 70-80% of patients.  Patients may be headache free by 2 hours if they treat with a triptan at onset of their migraine. DHE has no headache free data but Migranal nasal spray may provide relief in 61% of migraine patients at 2 hours if used at onset.

Many migraine patients use over the counter drugs such as supplements, caffeine, NSAIDS like Aleve and Advil, or doctor prescription prescribed narcotics like hydrocodone, and butalbital.

These drugs provide a variable clinical response and the narcotics should not be used for migraine because they lead straight into medication overuse headache.

But insurance cover for triptans is spotty and some patients don’t respond or have limiting medical issues so they can’t take them.

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This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, podcaster, YouTube video producer, and blogger.

Triptans for Migraine Treatment.  Triptans are the first choice for acute migraine treatment.  They are recommended by migraine headache authorities and they are all generic and reasonably priced with insurance.

Injectable sumatriptan 6 mg subcutaneous is the best all round drug because it works in 10 minutes and gives the highest dose in the brain of medication-100 mg.

Related questions

What is the triptan response rate?

About 20% of patients don’t respond to triptans or have a contraindication like previous heart attack, coronary artery disease, or out of control hypertension.

Modern treatment for migraine patients should be a trial of one or more of the triptans, the doctor adjusting the dose or trying a new drug on the follow-up clinic visit.

What is the best treatment dose?

Patients should always be advised to treat at onset and trying different doses, using a low dose to high dose mind set.

What is insurance coverage of Triptans like?

There are 7 triptans and they all are generic now and it is doubtful more will be made.  Insurance coverage of triptans shouldn’t be an issue, but it is a big issue in headache practice since insurance companies have different “tiers” of drugs.

Their tier 1 drug will be cheaper for the patient and represents a financial deal they have made with pharmaceutical providers, but it is a deal that has nothing to do with the reasonable practice of medicine where the doctor, reading the literature and using his practice experience, tries to make the best drug decision for a patient.

The rarely used triptans now are Amerge (naratriptan) and Axert (almotriptan).  Naratriptan onset is 1-2 hours, as is Frovatriptan, but Frovatriptan lasts the longest of any triptan—26 hours, so it has a special place in treating menstrual migraine.

What is the best triptan?

This question has never been answered.  Imitrex (sumatriptan) was the first and has always been the most popular drug and it comes in more applications—Sub Cutaneous, 2 forms of Nasal Spray, 3 different sized oral pills, and mixed with naproxen.

Frova (frovatriptan) has a special place in treating menstrual migraine.  The other short onset triptans—Maxalt (rizatriptan), Zomig (zolmitriptan), and Relpax (eletriptan) are commonly used and effective.

The generic short onset triptans have an onset of 30 minutes while name brand Imitrex, and Treximet both work in 15 minutes.  Time of treatment is a big deal in the migraine world, but few patients want to pay for name brand Imitrex or take the shot because of rejection of needles.

The question of “Which is the best triptan?”  could only be answered by a large drug trial using all the drugs and seeing who wins.  But now all the drugs are generic and insurance companies would have to pay for the study it will never be done.

Imitrex (sumatriptan) has a duration of 2 hours, while Relpax (eletriptan) is advertised for its long duration of 6 hours.  No journal on headache or article ever named the best drug, until 4 years ago when the American Academy of Neurology headache group broke the ice and reported the best drug overall, and it was no surprise; they named injectable SC Imitrex (sumatriptan) 6 mg as the best triptan, the first and now the best.

Data I have seen on Imitrex (and I don’t know if for other triptans), is that Imitrex (sumatriptan) SC 6 mg works in 10 minutes and gives a level in the brain of 100 mg.  Nasal spray Imitrex (sumatriptan) works in 10 minutes and gives a brain level of 10 mg.  Oral tablet form sumatriptan works in 30 minutes and gives a brain level of 30 mg.

No surprise here, nasal sprays give low drug levels.  So, injectable Imitrex (sumatriptan) works 3 times faster than oral and gives a blood level that is 3 times higher.  Glaxo, the drug firm that brought out injectable Imitrex, put their money on the sure winner—injectable SC Imitrex.

The original Glaxo drug trial for the FDA looked at 6 mg, 4 mg, and 3 mg doses and they all are available now and work pretty well, with decreasing incident of side effects according to dose.

For the needle shy there is pressure jet 6 mg DosePro which is a system that drives sumatriptan through the skin and into the body.

A final triptan comment is that when Glaxo’s name brand Imitrex ran out they brought out Treximet which is a combo drug of sumatriptan and naproxen.  Glaxo got Treximet through the FDA because for some migraine patients, it worked better than Imitrex alone.

Naproxen lasts 12 hours and is an NSAID.  After Treximet came out naproxen was tried with all the other oral triptans and found to work better for some patients.  I generally ask the patient to just try the triptan first alone, but if they are not satisfied to next try it with 2 Aleve which is 400 mg of naproxen.

Are there any new acute therapy migraine drugs?

There are several new drugs for acute migraine treatment available in 2020.  And they are:

Nurtec (Rimegepant)

Ubrelvy (Ubrogepant)

Reyvow (lasmiditan)

How well do the new drugs work?

How well do these drugs work in comparison with triptans?  These 3 drugs decrease symptoms of migraine attacks and improve function compared with placebo.  They may be helpful for the 20% of patients who are unable to take triptans.

How do these new drugs work?

They are all oral drugs.  Nurtec and Ubrelvy blocks the CGRP receptor.  CGRP is one of the inflammatory neurochemicals released by the migraine process.

Reyvow works on 5HT 1E receptors which inhibit trigeminal nerve pain pathways.  Reyvow also inhibits release of neurotransmitters and neuropeptides. 

Reyvow does not cause arterial vasoconstriction like triptans do and can be used in patients with heart disease, stroke, and hypertension. 

What is the expense of these new drugs?

Both sumatriptan and eletriptan are less expensive and more effective than the newer agents.

Nurtec (Rimegepant) is administered as a fast acting orally disintegrating single dosed  75 mg tablet in patients with episodic or chronic migraine.  The study demonstrated a statistically significant reduction from baseline in monthly migraine days in individuals treated with rimegepant compared with placebo.

Treatment provided pain relief within 1 hour.  Nurtec (Rimegepant) had a sustained efficacy of pain relief lasting as long as 48 hours for many patients.

This is an unusual drug that works quickly for acute therapy, but also has been approved for episodic and chronic migraine prevention.

Ubrelvy (Ubrogepant)  20% of patients who received 50 or 100 mg of Ubrogepant orally had freedom from headache pain at 2 hours.  The FDA approved Ubrelvy (Ubrogepant) for acute treatment of migraine.

Ubrelvy (Ubrogepant) has no effect of vasoconstriction and is okay with heart or stroke conditions.

Reyvow (lasmiditan) is the first and only Ditan for the acute treatment of migraine with or without aura.  Reyvow (lasmiditan) is not indicated for the  preventive treatment of migraine.

Dosing  Three oral dose sizes of Reyvow (lasmiditan) exist-50, 100, and 200 mg.  Only 1 dose should be taken in 24 hours.

A single dose of Reyvow (lasmiditan) may cause significant driving impairment due to increased sleepiness lasting as long as 8 hours.

Therefore, because of this possible side effect patients are advised to not perform potentially hazardous activities requiring complete mental alertness, such as driving a motor vehicle or operating machinery for at least 8 hours after each dose of Reyvow (lasmiditan).

Rimegepant and Ubrogepant both block CGRP activity while Lasmiditan is a serotonin (5-HT) 1F receptor agonist.

All migraine patients who don’t respond well to triptans, and that is about 20% of patients, should discuss these new drugs with their neurologists.

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