Role of Oral Gepants and Triptans in Treating Migraines
Stepped Care Approach to Migraine Treatment
- The American Academy of Neurology recommends triptans as second-line therapy for migraine after NSAIDs, while gepants are recommended as third-line therapy when triptans fail or are contraindicated 1, 2, 3
- NSAIDs with proven efficacy (acetylsalicylic acid, ibuprofen, and diclofenac potassium) should be used as first-line medications for acute migraine treatment 4, 5
- Paracetamol has less efficacy and should only be used in patients intolerant to NSAIDs 4
Second-Line Therapy: Triptans
- Triptans should be offered when over-the-counter analgesics provide inadequate relief 5, 6
- Triptans are most effective when taken early in an attack while headache pain is still mild 5
- No evidence supports using triptans during the aura phase 5
- If one triptan is ineffective, others might still provide relief 5
- For patients who rapidly reach peak headache intensity or cannot take oral triptans due to vomiting, sumatriptan by subcutaneous injection is recommended 5
Third-Line Therapy: Gepants
- Gepants (ubrogepant, rimegepant) should be used when all available triptans fail after an adequate trial period or when triptans are contraindicated 5, 6
Comparative Efficacy and Safety
- Triptans have well-documented effectiveness for acute migraine treatment 5
- Triptans have a risk of medication overuse headache with repeated use 5
Special Considerations
- Upon relapse, patients can repeat triptan treatment or combine with fast-acting NSAIDs 5
- Caution: repeating treatment increases risk of medication overuse headache 5
- For patients experiencing nausea/vomiting during attacks, prokinetic antiemetics (domperidone, metoclopramide) are useful adjuncts 5
- Adding an antiemetic is recommended when nausea is a significant component of the migraine 7
- Oral ergot alkaloids and opioids/barbiturates should be avoided due to poor efficacy and potential toxicity 5
Practical Algorithm for Treatment Selection
- Start with NSAIDs (ibuprofen, aspirin, diclofenac) for mild-moderate attacks 4
- If inadequate response to NSAIDs, prescribe a triptan 5
- If one triptan fails, try another triptan or a different formulation 5, 7
- If all triptans fail or are contraindicated, use a gepant (rimegepant, ubrogepant) 5
- Consider combination therapy (triptan + NSAID) for difficult-to-treat attacks 5