Triptans

There are 7 Triptans on the market and all of the tablets are now available in generic. Their low cost (2 of them are < $1 per treatment) will insure they continue to be a first line treatment for acute migraine headache treatment.

Sumatriptan

Imitrex® was the first triptan brought to market. Sumatriptan is the generic name name for Imitrex and is available as an injection, nasal spray, nasal powder and tablet. The sumatriptan injection is associated with the highest incidence of side effects, which can be annoying but are quite transient. Another problem with the injection is its relatively high price compared to the tablet. The tablet is the most convenient, easiest, and commonly used form of sumatriptan. The injection, however, is clearly the fastest migraine reliever on the market. The combination of sumatriptan with the NSAID naproxen is called Treximet® and is now also available as a generic. It is clear the combination of sumatriptan with naproxen works better than either by itself. An alternative to both the injection and tablet is the sumatriptan nasal spray, which sometimes works faster than the tablet.

Onzetra® and Tosymra® – New formulations of Sumatriptan

A newer form of sumatriptan available is called Onzetra®. It is a 10 mg nasal powder that is blown into the nose through a mouth piece. This results in a lower dose of sumatriptan (the blood levels of sumatriptan are measured to be no higher than an oral 50 mg sumatriptan tablet) that gets delivered faster than the sumatriptan 20 mg nasal spray with fewer side effects compared to the either the 4 or 6 mg sumatriptan shots and is even less likely to cause triptan side effects compared to the 100 mg sumatriptan tablet.

Tosymra®, another new sumatriptan formulation, is a 10 mg nasal spray. It generates like blood levels equivalent to a sumatriptan 6 mg sq shot without a needle.

Sumatriptan tablets are available for less than $1 per dose using Goodrx.com. The only formulations that are not available in a generic are the newest ones – Onzetra® and Tosymra®.

Zolmitriptan

Another triptan offered in multiple treatment formulations is Zomig® (zolmitriptan). Zolmitriptan comes in a tablet, dissolving tablet and nasal spray. The tablet and dissolving tablet are of equal efficacy with nearly identical times of onset to headache relief. By comparison, the zolmitriptan nasal spray has an onset that is significantly faster than either the zolmitriptan tablet or the dissolving tablet but the zolmitriptan nasal spray is not as fast as the sumatriptan injection. The nasal spray may be effective in patients who do not respond to the tablets. Studies of the zolmitriptan nasal spray did not exclude patients who were already using zolmitriptan tablets and this may have biased the results. Without head-to-head data of patients who have never used a triptan nasal spray, it is impossible to say with certainty if zolmitriptan or sumatriptan works faster.

Rizatriptan

Maxalt® (rizatriptan), like Zomig® comes in a tablet and a dissolvable tablet form. It is important to note that the dissolvable tablet is not absorbed more quickly into the bloodstream than the tablet.

Naratriptan, Almotriptan, Frovatriptan, Eletriptan

The other triptans on the market; Amerge® (naratriptan), Axert® (almotriptan), Frova® (frovatriptan), and Relpax® (eletriptan) are only available in tablet form.

Do any triptan tablets work faster than others?

The oral tablets are divided into two groups, the fast acting and slower acting. The faster acting group (cheapest to most expensive) includes sumatriptan, rizatriptan, eletriptan, zolmitriptan, and almotriptan. The slower acting group includes naratriptan and frovatriptan. In practice, the time gap between the fast acting and slow acting is not that different.

Compared to over the counter treatments, most patients prefer a triptan. They have also been shown to be cost effective. A typical response to the fast acting tablets will be substantial pain relief in less than 2 hours. The sumatriptan injection and nasal powder can begin working in less than 15 minutes. Occasionally, the triptans are used in migraine prevention where the trigger is clearly identified and predictable such as with menstrual cycles for example.

Triptans are less likely to work when the headaches are daily or near daily.  If a patient has headaches more than twice per week, Dr. Loftus will likely also work on a preventive plan for their migraines.

Which triptan should I use for my migraine headache?

The answer is relatively simple. Patients should use the triptan that works best for them. Generally at least 3 are tried before moving to more expensive acute treatment options like devices. It is not possible to predict an individual patient’s response to a specific triptan.

The following table shows a comparison of the various triptans, the formulation that is available and their consumer characteristics.