Talkin' bout Triptans

I tell patients that the only "headache free" data for migraine treatment is with triptans and 70-80% of migraine patients may be headache free by 2 hours if they treat with a triptan at onset of their migraine.  DHE has no headache free data but Migranal nasal spray may provide relief in 61% of migraine patients at 2 hours if used at onset.

From this statement one can see that really Triptans are the first choice go to acute migraine treatment drugs, but about 20% of patients don’t respond or have a contraindication like previous heart attack, coronary artery disease, or out of control hypertension.  Therefore, most modern treatment for migraine patients should be a trial of several of the triptans, taking at onset and trying different doses, always using a low dose to high dose mind set.

There are 7 triptans and they all are generic now and it is doubtful more will be made.  Also, although insurance coverage of triptans shouldn’t be an issue, it is a big issue in headache practice.  Insurance companies have what they call different “tiers” of drugs.  Their tier 1 drug will be cheaper for the patient and represents a financial deal they have made with pharmaceutical providers, but it is a deal that has nothing to do with the reasonable practice of medicine where the doctor, reading the literature and using his practice experience, tries to make the best drug decision for a patient.

The rarely used triptans now are Amerge (naratriptan) and Axert (almotriptan).  Naratriptan onset is 1-2 hours, as is Frovatriptan, but Frovatriptan lasts the longest of any triptan—26 hours, so it has a special place in treating menstrual migraine.

Imitrex (sumatriptan) was the first and has always been the most popular drug and it comes in more applications—SC, 2 forms of NS, 3 different sized oral pills, mixed with naproxen.  Frova (frovatriptan) has a special place in treating menstrual migraine.  The other short onset triptans—Maxalt (rizatriptan), Zomig (zolmatriptan), and Relpax (eletriptan) are commonly used and effective.

Covert information is that all the generic short onset triptans have an onset of 30 minutes while name brand Imitrex, and Treximet both work in 15 minutes.  Time is pain relief in the migraine world, but few patients want to pay for name brand Imitrex.

The question has always been “Which is the best triptan?”  That question could only be answered by a large drug trial using all the drugs and seeing who wins.  It was never done and probably never will be.  Imitrex (sumatriptan) has a duration of 2 hours, while Relpax (eletriptan) is advertised for its long duration of 6 hours.  No journal on headache or article ever named the best drug, until 4 years ago when the American Academy of Neurology headache group broke the ice and reported the best drug overall, and it was no surprise; they named injectable SC Imitrex (sumatriptan) as the best triptan, the first and now the best.

Data I have seen on Imitrex (and I don’t know if for other triptans), is that Imitrex (sumatriptan) SC 6 mg works in 10 minutes and gives a level in the brain of 100 mg.  Nasal spray Imitrex (sumatriptan) works in 10 minutes and gives a brain level of 10 mg.  No surprise here, nasal sprays give low drug levels.  Oral Imitrex (sumatriptan) works in 15/30 minutes and gives a level in the brain of 30 mg.  So, injectable Imitrex (sumatriptan) works 3 times faster than oral and gives a blood level that is 3 times higher.  Glaxo, the drug firm that brought out injectable Imitrex, put their money on the sure winner—injectable SC Imitrex.  The original Glaxo drug trial for the FDA looked at 6 mg, 4 mg, and 3 mg doses and they all are available now and work pretty well, with decreasing incident of side effects according to dose.  For the needle shy there is pressure jet 6 mg DosePro which is a system that drives sumatriptan through the skin and into the body.

A final triptan comment is that at the end of Glaxo’s name brand Imitrex run (8 years before the copyright runs out) they brought out Treximet which is a combo drug of sumatriptan and naproxen.  Glaxo got it through the FDA because for some migraine patients, it worked better than Imitrex alone.  Naproxen lasts 12 hours and is an NSAID.  After this naproxen was tried with all the other oral triptans and found to work better for some patients.  I generally ask the patient to just try the triptan first alone, but if they are not satisfied to next try it with 2 Aleve which is 400 mg of naproxen.