Drug update: Moderately severe migraine headaches. (Clinical Rounds).

Triptans have revolutionized the treatment of migraines. More formally known as selective serotonin receptor agonists, triptans are clearly the first class of drugs physicians should consider when treating most patients with migraine headaches that are moderate to severe. Analgesics and nonsteroidal anti-inflammatory drugs are the first-line treatment for patients with mild migraine headaches, and they also are a good first choice for more severe migraines. But by the time most patients seek medical help for moderately severe migraine headaches, they have usually already tried analgesics and NSAIDs on their own, without success.

Ergot derivatives are another option for moderately severe migraine headaches, but in general they're considered inferior to the triptans. Opiates are generally avoided except as a last resort.

The route of delivery can have a major impact on the treatment outcome. Since migraines are often accompanied by nausea and vomiting, oral formulations may not be best. The response rate to the nasal spray form of sumatriptan is similar to that of the oral form. This dosing route is often recommended for adolescents or patients who experience early-morning migraines. The major drawback of nasal sprays is that many patients complain of a bitter aftertaste. An injectable form of sumatriptan is also very effective but is less convenient.

Little clinical data exist to guide the choice of migraine treatment in women who are pregnant or breast-feeding. Avoid triptans and ergot derivatives in these women. For women with severe, persistent, recurring migraines, narcotics and antiemetics may be used to relieve debilitating symptoms. Most pregnant migraineurs have a decrease in the frequency and intensity of their attacks. For breast-feeding women, one possible strategy is to pump breast milk shortly after dosing, then discard it and substitute formula for the next feeding.

In elderly patients, avoid triptans if heart disease is present. For most elderly patients, an analgesic or NSAID is adequate.

Comprehensive guidelines on managing acute migraine headaches were compiled by the American Academy of Neurology and the U.S. Headache Consortium in 2000, and were recently endorsed by the American College of Physicians--American Society of Internal Medicine. The guidelines can be found at http://www.aan.com/public/practiceguidelines/headache_gl.htm.

 
TRIPTANS 
 
The major drug class for treating patients with more than mild migraine. 
These drugs are probably more specific for treating migraine 
pathophysiology than are the ergot derivatives, and they have fewer 
adverse effects. Also relieve symptoms such as nausea, vomiting, and 
sensitivity to light and sound. Study results suggest that about 
two-thirds of patients respond to at least one drug from class. Patients 
who fail to respond to one drug in class should try at least one other 
before abandoning class. Landmark metaanalysis of trial results, 
published last November (Lancet 358[9294]:1668-75, 2001), identified 
small but important differences in efficacy among drugs in class. Safety 
is similar among drugs in class, but tolerability differs. Route of 
administration and experience with agent may also influence drug choice. 
Some drugs in class have a longer serum half-life, suggesting a possible 
difference in duration of action, but clinical relevance of this has not 
been clearly shown. 
 
Drug          Dose          Cost/Dose * 
 
sumatriptan   25-100 mg     $16.49 
(Imitrex)     (oral)        (100 mg) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
almotriptan   6.25-12.5 mg  $10.55 
(Axert) 
 
 
 
 
 
frovatriptan  2.5 mg        not available 
(Frova) 
 
 
 
 
 
 
 
 
 
 
naratriptan   1-2.5 mg      $18.46 
(Amerge) 
 
 
rizatriptan   5-10 mg       $15.52 
(Maxalt) 
 
 
 
 
zolmitriptan  2.5-5 mg      $16.72 
(Zomig)                     (5 mg) 
 
 
 
 
 
Drug          Comment ** 
 
sumatriptan   Triptan that's been on the U.S. market the longest, so 
(Imitrex)     the first one-some physicians use. Metaanalysis results 
              placed sumatriptan (at a dose of 100 mg) in the middle 
              of the pack for efficacy and tolerability. Unique among 
              the triptans, it's available in nasal spray, injectable, 
              and oral formulations. Subcutaneous sumatriptan at a 
              dose of 6 mg works quickly and produces better response 
              rates than any oral triptan. But patients must 
              self-inject, and adverse effects are more intense and 
              more prevalent than with oral formulation. Nasal spray 
              is for patients too nauseated to use an oral drug and 
              for adolescents. An intranasal dose of 20 mg is the only 
              triptan dose proved effective in adolescents. In 
              clinical trials, patients using nasal spray did better 
              with an initial dose of 20 mg. ...