II. Indications

  1. Migraine Abortive Treatment (age 12 years and older)
  2. Cluster Headache (off-label except for Sumatriptan)
  3. Controversial cohorts in whom Triptan use is now thought safe (Cardiovascular Risk Factors)
    1. Controlled Diabetes Mellitus
    2. Controlled Hypertension
    3. Controlled Hyperlipidemia
    4. Postmenopausal women
    5. Men over age 40 years

III. Contraindications

  1. Sulfa Allergy (relative contraindication)
    1. Almotriptan is a Sulfonamide with risk of Sulfa Allergy
  2. Coronary Artery Disease
  3. Prinzmetal's Angina
  4. Uncontrolled Hypertension
  5. Basilar Artery Migraine
  6. Familial Hemiplegic Migraine
  7. Ischemic Cerebrovascular Accident
  8. Pregnancy
  9. Concurrent Medication use (absolute contraindications)
    1. MAO Inhibitor use
    2. Ergotamine use in prior 24 hours

IV. Mechanism

  1. Serotonergic 5-HT1 receptor Agonists
  2. Inhibits sensory dural nerve fiber neuropeptide release
  3. Intracranial extracerebral artery Vasoconstriction
    1. Mediated by Triptan direct effect on cerebrovascular Smooth Muscle

V. Dosing: General

  1. Screen for cardiovascular disease before use!
  2. Limit to no more than twice weekly

VI. Medications

  1. Almotriptan (Axert) tablets 6.25 mg, 12.5 mg

VII. Dosing

  1. Indicated in adults and children age 12 years and older
  2. Initial: 6.25 to 12.5 mg orally; may repeat in 2 hours
  3. Maximum: 2 doses (or 25 mg total) in 24 hours
  4. Indications to limit to 6.25 mg (lower dose)
    1. Hepatic Impairment
    2. Severe renal Impairment

VIII. Adverse Effects

  1. See Triptan Overdose
  2. Sulfa Allergy
    1. Almotriptan is a Sulfonamide with risk of Sulfa Allergy
  3. Vasospasm
    1. Generally benign in low risk populations
    2. Avoid in Coronary Artery Disease, Cerebrovascular Disease, Peripheral Arterial Disease
    3. Also avoid in hemiplegic Migraine or basilar Migraine
  4. Medication Overuse Headaches
    1. Highest risk with >10 doses per month
    2. Limit to two doses weekly

IX. Safety

  1. Unknown safety in Lactation
  2. Pregnancy Category C (most Triptans, but generally avoided in pregnancy)
    1. See Migraine Medications in Pregnancy
    2. Not recommended for routine use in pregnancy
    3. Consult obstetrics before use
    4. May be considered if Migraines are uncontrolled, debilitating
      1. If used, Sumatriptan has the longest safety data
    5. Adverse effects in pregnancy
      1. Avoid in first trimester (fetal malformations and adverse pregnancy outcomes)
      2. Risk of uterine atony and peripartum Hemorrhage (but may be considered in debilitating Headache)
      3. Associated with hyperactivity and emotionality at age 3 in exposed children (AHRQ)
    6. References
      1. Nezvalova-Henriksen (2010) Headache 50(4): 563-75 +PMID: 20132339 [PubMed]

X. Drug Interactions

  1. See absolute contraindications above
    1. Ergotamine
    2. MAO Inhibitors
  2. Lithium
  3. Selective Serotonin Reuptake Inhibitor (SSRI)
    1. Risk of Serotonin Syndrome when combined with SSRI, SNRI or MAO Inhibitors

XI. Efficacy: General

  1. Most effective oral agents (compared with Imitrex 100 mg PO)
    1. Rizatriptan (Maxalt) 10 mg orally
    2. Eletriptan (Relpax) 80 mg orally
    3. Almotriptan (Axert) 12.5 mg orally (least side effects)
  2. References
    1. Ferrari (2001) Lancet 358:1668-75 [PubMed]

XII. Management: Overdose or Toxicity

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Related Studies

Cost: Medications

almotriptan (on 1/18/2023 at Medicaid.Gov Survey of pharmacy drug pricing)
ALMOTRIPTAN MALATE 12.5 MG TAB Generic $21.98 each
ALMOTRIPTAN MALATE 6.25 MG TAB Generic $17.11 each