Pharm

Triptan

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Triptan, Sumatriptan, Imitrex, Rizatriptan, Maxalt, Zolmitriptan, Zomig, Naratriptan, Amerge, Eletriptan, Relpax, Frovatriptan, Frova, Treximet

  • Contraindications
  1. Coronary Artery Disease
  2. Uncontrolled Hypertension
  3. Basilar Artery Migraine
  4. Familial Hemiplegic Migraine
  5. Ischemic Cerebrovascular Accident
  6. Prinzmetal's Angina
  7. Pregnancy
  8. Concurrent Medication use (absolute contraindications)
    1. MAO inhibitor use
    2. Ergotamine use in prior 24 hours
  • Controversial cohorts in whom Triptan use is thought safe
  1. Controlled Diabetes Mellitus
  2. Controlled Hypertension
  3. Controlled Hyperlipidemia
  4. Postmenopausal women
  5. Men over age 40 years
  • 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
  1. Screen for cardiac disease before use!
  2. Limit to no more than twice weekly
  • 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. Initial: 25 mg PO
    2. Repeat 25 to 100 mg PO every 2 hours prn
    3. Maximum: 300 mg/day
    4. 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
  • Dosing
  • Rizatriptan (Maxalt, Maxalt MLT)
  1. Initial: 5 to 10 mg PO (MLT form is lingual)
  2. Repeat dose in 2 hours
  3. Maximum: 30 mg in 24 hours
  • Dosing
  • Naratriptan (Amerge)
  1. Initial: 1 to 2.5 mg PO
  2. Repeat in 4 hours
  3. Maximum: 5 mg in 24 hours
  • Dosing
  • Zolmitriptan (Zomig)
  1. Oral
    1. Initial: 1.25 to 2.5 mg PO
    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)
  • Dosing
  • Eletriptan (Relpax)
  1. Initial: 20 to 40 mg PO
  2. May repeat dose in 2 hours
  3. Maximum: 40 mg/dose or 80 mg/day
  • Dosing
  • Almotriptan (Axert)
  1. Initial: 6.25 to 12.5 mg PO; may repeat in 2 hours
  2. Maximum: 2 doses in 24 hours
  • Dosing
  • Frovatriptan (Frova)
  1. Initial dosing: 2.5 mg PO; may repeat in 2 hours
  2. Maximum dose: 7.5 mg per day
  • Adverse Effects
  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
  • 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]
  1. Most effective oral agents (c/w Imitrex 100 mg PO)
    1. Rizatriptan (Maxalt) 10 mg PO
    2. Eletriptan (Relpax) 80 mg PO
    3. Almotriptan (Axert) 12.5 mg PO (least side effects)
  2. References
    1. Ferrari (2001) Lancet 358:1668-75 [PubMed]