A large number of patients with migraine do not see a physician for their migraines. They take over the counter pain medications or simply suffer with their headaches. Prior to the 1990’s, the prescription medications available for migraines were either narcotics (which are potentially addicting and make people drowsy) or not very effective. The 1990’s have brought a revolution of treatment for migraine with the release of a new class of medication, the triptans. The triptans are available in multiple forms (tablets, nasal spray, subcutaneous injection) and are extremely safe. They are clearly more effective than the medications that were previously available for migraines.

Imitrex® (sumatriptan) was the first triptan brought to market. Imitrex is available as a shot, nasal spray, and tablet. The shot is clearly the fastest migraine reliever on the market. The nasal spray is a little faster than the tablet (at least for some patients). The tablets are clearly the most convenient to use and the cheapest. For this reason, tablets are the most widely used for of Imitrex. The injection is associated with the highest incidence of side effects. These side effects can be annoying but are quite transient. The exception is to not use this class in patients with ischemic heart disease. The combination of imitrex with an NSAID is under development at this time. You can find my personal story about Imitrex and more information on this web page.

Zomig® (zolmitriptan) is the only other triptan offered in multiple forms. Available for several years in the US as either a tablet or dissolving tablet, it is now offered as a nasal spray as well. The tablet and dissolving tablet are of equal efficacy with nearly identical times of onset for headache relief. By comparison, the nasal spray has an onset that is significantly faster than the tablet. In addition, the nasal spray may be effective in patients who do not respond to the tablets. I say may be effective because the studies I have seen included patients who were potentially already using Zomig® tablets and this could have biased the results. Without head-to-head data in triptan naive patients it is impossible to say with certainty but it appears the imitrex injection is still somewhat faster than the Zomig nasal spray but this appears to be the second fastest option.

The other triptans (Amerge®, Axert®, Frova®, Maxalt®, Relpax®) are only available in tablet form. Maxalt®, like Zomig® come in a dissolvable form but this form is not more quickly absorbed than the oral tablet. The oral tablets are divided into two groups, the fast acting and slower acting. The faster acting group includes Axert®, Imitrex®, Maxalt®, Relpax® and Zomig®. The slower acting group includes Amerge® and Frova®.

Despite what others will claim, I do not believe that any of the fast acting oral triptans can claim superiority to any other oral triptan medication. The studies demonstrating Relpax® superiority to other oral triptans have several design flaws. The most significant, in my opinion, is the inclusion of patients who previously used the competitor's medication in the study. I have reviewed the Relpax® versus Encapsulated Sumatriptan studies in detail. Both current Imitrex® users (which would actually favor Imitrex®) and prior users (which would favor Relpax®) are included. In addition, the Sumatriptan used has never been shown to be bioequivalent to brand name Imitrex® in migraine patients. The company and author has data which could address some of these concerns but will not share it.

The triptans should not be used in patients with ischemic heart disease. All of the oral triptans cause a small degree of contraction of the coronary artery vessels (about 5% or so). This is obviously not significant to patients unless a large percentage of the vessel is blocked by an obstruction in the artery known as a plaque. The exact testing which should be performed, if any, is individualized by each physician for their patient but it should be noted the primary cause of heart attack in the age group of migraine patients would be from plaque rupture (a sudden opening of the plaque and clot formation) and not from a slow narrowing of the artery.

The triptans have been shown to be preferred by patients not currently satisfied with their current migraine pain. They have even been shown to be cost effective. A typical response for the fast acting tablets will be substantial pain relief in under 2 hours. The shot can begin working in less than 15 minutes. Occasionally, the triptans are used in migraine prophylaxis where the trigger is clearly identified and predictable (menstrual cycles for example). Triptans do not work when the headaches are daily and work much less well when the headaches are nearly daily.

Which triptan should one therefore use? I think the answer is relativley simple. Patients should use the triptan that works best for them. In my practice, if a fast acting triptan is being prescribed, I give the patient 2 tablets of each of the 5 medications to try on different headaches. I am not sure how well this sorts out the one that is best for a particular patient, but it seems to be more reasonable than any other method I can think of.

For those patients who are not responders to triptans, there is another medication known as nasal DHE or Migranal®. This medication, like the triptans, should not be used in someone with ischemic heart disease. The response of the migraine to Migranal® is similar to the fast acting oral agents. Like the triptans, the Migranal® treats the total migraine. It should not be used in conjunction with any of the triptans.

Dr. Loftus and the Diagnostic Clinic of Houston participates in migraine treatment and migraine prevention studies. If you are willing to come to Houston for this study, please use this email and we will update you when more information is available.

Who Treats Migraines?