II. 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

III. Indications: General

  1. Migraine Abortive Treatment
  2. Cluster Headache
  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

IV. Contraindications

  1. Coronary Artery Disease
  2. Prinzmetal's Angina
  3. Uncontrolled Hypertension
  4. Basilar Artery Migraine
  5. Familial Hemiplegic Migraine
  6. Ischemic Cerebrovascular Accident
  7. Pregnancy
  8. Concurrent Medication use (absolute contraindications)
    1. MAO Inhibitor use
    2. Ergotamine use in prior 24 hours

V. 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
  4. Propranolol with Rizatriptan
    1. Requires reducing Rizatriptan dose

VI. Dosing: General

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

VII. Dosing: Sumatriptan (Imitrex)

  1. Subcutaneous Sumatriptan
    1. Initial: 6 mg SC
    2. Repeat in 12 hours prn
    3. Maximum: 12 mg/day
    4. Even generic dosing approaches $100/dose
  2. Oral Sumatriptan
    1. Dose 25 to 100 mg orally every 2 hours prn
      1. Start at max single dose, 100 mg orally for best efficacy in young adult without contraindications
    2. Maximum: 300 mg/day
    3. Generic dosing may be as low as $3/dose
  3. Intranasal Sumatriptan
    1. Initial: 5, 10 or 20 mg intranasal
      1. Dose responsive (20 mg more effective)
    2. Repeat after 2 hours prn
    3. Maximum: 40 mg/day
    4. Safety of use in over 4 Headaches per month not known
  4. Treximet (combination with Naproxen)
    1. Contains Sumatriptan 85 mg with Naproxen 500 mg
    2. Released as Sumatriptan becomes generically available
    3. Cheaper to purchase generic Sumatriptan (when available) and Naproxen separately
  5. Other Sumatriptan formulations
    1. Zecurity patch
      1. Removed from market 2016 due to serious adverse effects including burns
      2. http://www.fda.gov/Drugs/DrugSafety/ucm504588.htm

VIII. Dosing: Rizatriptan (Maxalt, Maxalt MLT)

  1. Initial: 5 to 10 mg orally (MLT form is lingual)
    1. Start at max single dose, 10 mg orally for best efficacy in young adult without contraindications
  2. Repeat dose in 2 hours
  3. Maximum: 30 mg in 24 hours

IX. Dosing: Naratriptan (Amerge)

  1. Initial: 1 to 2.5 mg orally
  2. Repeat in 4 hours
  3. Maximum: 5 mg in 24 hours
  4. Generic options available, but more expensive than Sumatriptan, Rizatriptan
  5. Consider for longer lasting Migraines (but have delayed onset)

X. Dosing: Zolmitriptan (Zomig)

  1. Oral
    1. Initial: 1.25 to 2.5 mg orally
    2. Repeat dose every 2 hours
    3. Maximum: 10 mg in 24 hours
  2. Intranasal
    1. Dose: 5 mg spray (single dose unit)
    2. Onset: 15 minutes (faster than oral preparations)

XI. Dosing: Eletriptan (Relpax)

  1. Initial: 20 to 40 mg orally
  2. May repeat dose in 2 hours
  3. Maximum: 40 mg/dose or 80 mg/day

XII. Dosing: Almotriptan (Axert)

  1. Initial: 6.25 to 12.5 mg orally; may repeat in 2 hours
  2. Maximum: 2 doses in 24 hours

XIII. Dosing: Frovatriptan (Frova)

  1. Initial dosing: 2.5 mg orally; may repeat in 2 hours
  2. Maximum dose: 7.5 mg per day
  3. Consider for longer lasting Migraines (but have delayed onset)

XIV. Adverse Effects: General

  1. Tingling, Flushing or burning Sensation at injection
  2. Heavy chest
    1. Generally benign in low risk populations
    2. Risk of Coronary Artery Disease exacerbation
  3. Terrible taste with intranasal preparations

XV. Efficacy: Sumatriptan

  1. Efficacy dependent on mode of drug delivery
    1. Subcutaneous effective in 80% of patients
    2. Intranasal effective in 70% of patients
    3. Oral effective in 60% of patients
  2. Oral form does not prevent Migraine recurrence
    1. Rapoport (1995) Neurology 45:1505-9 [PubMed]

XVI. 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]

XVII. Management: Overdose or Toxicity

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Related Studies

Cost: Medications

sumatriptan (on 10/19/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
SUMATRIPTAN 20 MG NASAL SPRAY Generic $19.13 each
SUMATRIPTAN 4 MG/0.5 ML INJECT Generic $132.25 per ml
SUMATRIPTAN 5 MG NASAL SPRAY Generic $36.07 each
SUMATRIPTAN 6 MG/0.5 ML AUTOINJ Generic $65.60 per ml
SUMATRIPTAN 6 MG/0.5 ML CART Generic $113.31 per ml
SUMATRIPTAN 6 MG/0.5 ML INJECT Generic $65.02 per ml
SUMATRIPTAN 6 MG/0.5 ML VIAL Generic $16.71 per ml
SUMATRIPTAN SUCC 100 MG TABLET Generic $0.50 each
SUMATRIPTAN SUCC 25 MG TABLET Generic $0.60 each
SUMATRIPTAN SUCC 50 MG TABLET Generic $0.43 each
SUMATRIPTAN-NAPROXEN 85-500 MG Generic $26.51 each
imitrex (on 1/1/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
IMITREX 100 MG TABLET Generic $0.50 each
IMITREX 20 MG NASAL SPRAY Generic $19.13 each
IMITREX 5 MG NASAL SPRAY Generic $36.07 each
IMITREX 50 MG TABLET Generic $0.43 each
IMITREX 6 MG/0.5 ML CARTRIDGES Generic $113.31 per ml
rizatriptan (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
RIZATRIPTAN 10 MG ODT Generic $0.74 each
RIZATRIPTAN 10 MG TABLET Generic $0.45 each
RIZATRIPTAN 5 MG ODT Generic $0.64 each
RIZATRIPTAN 5 MG TABLET Generic $0.55 each
zolmitriptan (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
ZOLMITRIPTAN 2.5 MG ODT Generic $4.43 each
ZOLMITRIPTAN 2.5 MG TABLET Generic $1.08 each
ZOLMITRIPTAN 5 MG NASAL SPRAY Generic $72.00 each
ZOLMITRIPTAN 5 MG ODT Generic $3.91 each
ZOLMITRIPTAN 5 MG TABLET Generic $1.46 each
zomig (on 11/23/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
ZOMIG 5 MG NASAL SPRAY Generic $72.00 each
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
eletriptan (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
ELETRIPTAN HBR 20 MG TABLET Generic $3.07 each
ELETRIPTAN HBR 40 MG TABLET Generic $2.60 each
relpax (on 3/15/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
RELPAX 40 MG TABLET Generic $2.60 each
frovatriptan (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
FROVATRIPTAN SUCC 2.5 MG TAB Generic $8.77 each
frova (on 1/1/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
FROVA 2.5 MG TABLET Generic $8.77 each