Acute Migraine Treatment with Triptans

Introduction to Triptans

The American Academy of Neurology recommends triptans as second-line therapy for acute migraine treatment when over-the-counter NSAIDs fail, with oral sumatriptan 50-100 mg, rizatriptan 10 mg, or eletriptan 40 mg being the most effective first-choice triptans based on efficacy, speed of onset, and consistency 1

Start with acetylsalicylic acid, ibuprofen, or diclofenac potassium before escalating to triptans, as recommended by the American Headache Society 1

Rizatriptan 10 mg provides the greatest early efficacy among oral triptans with best consistency (67% response in ≥2 of 3 attacks), according to the American Academy of Neurology 2
Subcutaneous sumatriptan 6 mg has the most rapid onset and greatest efficacy of all triptans, useful when oral route fails or patient reaches peak intensity rapidly, as stated by the American Headache Society 1, 4
Intranasal sumatriptan 5-10 mg has rapid absorption, significant pain-free rates at 15 minutes, and can be repeated after 2 hours, as recommended by the American Academy of Neurology 4

Take triptans early when headache is still mild for maximum effectiveness, as advised by the American Headache Society 1
Do NOT take during aura phase—no evidence of benefit, according to the American Academy of Neurology 1
Trial 2-3 migraine episodes before abandoning a specific triptan, as recommended by the American Headache Society 2, 4

Combine triptan with fast-acting NSAID (naproxen sodium, ibuprofen lysine, or diclofenac potassium) if monotherapy insufficient, as stated by the American Academy of Neurology 1, 4

Contraindications for all triptans include coronary artery disease or vasospasm, hemiplegic or basilar migraine, concurrent use with ergotamine derivatives, use within 24 hours of another triptan, MAOIs (within 2 weeks), uncontrolled hypertension, pregnancy, and severe hepatic impairment (sumatriptan), as listed by the American Headache Society 2, 4

Use orally disintegrating tablets (rizatriptan MLT, zolmitriptan) when nausea/vomiting present, as recommended by the American Academy of Neurology 2
Consider intranasal or subcutaneous routes when oral absorption unreliable, according to the American Headache Society 4
Add antiemetic for severe nausea/vomiting, as advised by the American Academy of Neurology 4