II. Indications: General

  1. Migraine Abortive Treatment (adults)
    1. Consider for longer lasting Migraine Headaches (but have delayed onset)
  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. Children
  2. Severe renal Impairment (eGFR <15 ml/min)
  3. Severe hepatic Impairment
  4. Coronary Artery Disease
  5. Prinzmetal's Angina
  6. Uncontrolled Hypertension
  7. Basilar Artery Migraine
  8. Familial Hemiplegic Migraine
  9. Ischemic Cerebrovascular Accident
  10. Pregnancy
  11. 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. Precautions

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

VI. Medications

  1. Naratriptan (Amerge)
    1. Tablets 1 mg, 2.5 mg
    2. Generic options available, but more expensive than Sumatriptan, Rizatriptan
    3. Consider for longer lasting Migraines (but have delayed onset)

VII. Dosing

  1. Only approved for use in adults
  2. Standard dosing
    1. Initial: 1 to 2.5 mg orally
    2. Repeat in 4 hours
    3. Maximum: 5 mg in 24 hours
  3. Decreased dosing in mild to moderate hepatic or renal Impairment
    1. Limit individual doses to 1 mg
    2. Limit daily total dose to 2.5 mg in 24 hours

VIII. Adverse Effects

  1. See Triptan Overdose
  2. 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
  3. 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 Unknown for insufficient data (most Triptans are category C, 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. Management: Overdose or Toxicity

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Related Studies

Cost: Medications

naratriptan (on 11/23/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
NARATRIPTAN HCL 1 MG TABLET Generic $1.31 each
NARATRIPTAN HCL 2.5 MG TABLET Generic $1.50 each