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Clinician’s Corner: Migraine headache treatment

The medications we discussed last week that we are not supposed to use for migraine headache treatment were the mainstay of therapy until the early 1990’s.  In December of 1992 Imitrex (sumatriptan) injection was approved by the FDA, and the oral dosage form was approved in June of 1995.  This profoundly changed acute migraine headache treatment.  Narcotics were no longer prescribed for headaches.

Mechanism:  they are laser focused to constrict blood vessels in the brain and decrease inflammation.

Adverse effects: tingling, sensation of warmth in neck & head chest and limbs.  Do not use triptans within 24 hours of ergots or other triptans.

Avoid use: heart attack patients, high blood pressure, other heart disease.  To reduce the potential for chest pains, do not give if risk factors: obesity, diabetes, high cholesterol, as well as smokers, men over 40 and post-menopausal women.

Selective Serotonin Receptor Agonists  (Triptans)

BRAND NAME GENERIC NAME Available Strength DOSAGE MAX DAILY DOSAGE ONSET

(in minutes)

Axert® Almotriptan Tablets 6.25, 12.5 12.5mg; repeat in 2 hours 25mg 60 min.
Imitrex® Sumatriptan Tablets 25,50 & 100mg 50-100mg, repeat in 2 hours 200mg 60-120min
    Nasal spray 5mg, 20mg 5 or 20mg. Repeat in 2 hours 40mg 15-20min
    Inject 6mg/.5ml

New:4mg/.5ml

6mg, repeat in 1 hour 12mg 10-15min
Treximet® Sumatriptan + naproxen 85/500 1 tablet ; may repeat in 2 hours. Max 2/day 170/1000 60-120 min
Relpax® Eletriptan Tablets 20 & 40mg 20mg-40 Repeat in 2 hours 80mg 60
Frova®

 

Frovatriptan 2.5mg 2.5mg repeat in 2 hours 7.5mg 60-120min
Maxalt®

 

Rizatriptan Tablet/wafer 5mg, 10mg 5 or 10mg. Repeat in 2 hours 30mg 30minutes
Zomig® Zolmitriptan Tablet/wafer 2.5mg, 5mg 2.5-5mg repeat in 2 hours 10mg 45 min.
Amerge® Naratriptan 1mg & 2.5mg 1mg or 2.5mg repeat in 4 hours 5mg 60min

COST: all the products above are available as generics.  However due to competition, or lack thereof, there is great variability in pricing of the generics.  Sumatriptan and Rizatriptan are the cheapest, with almotriptan and frovatriptan being the most expensive.

Why do we need 7 different triptans??????

  • If you fail on a triptan, the second choice might work better
  • Faster onset—injections work quicker (10-15 minutes) so do nasal sprays (15 minutes). Also, good if patient is vomiting. (note that orally disintegrating tablets do NOT work faster).
  • Long half-life drugs like Frovatriptan and Naratriptan may be more useful for menstrual migraines—more useful for prevention than to abort a headache.

The Headache Specialist says:  using TRIPTANS for Migraine

  • Reduces all aspects of migraine disability
  • Minimal or no drowsiness
  • Decreases nausea and vomiting
  • Drug induced headache is uncommon if use optimally. (Use high dose early)
  • Use 1 pill per headache

Your Thompson Pharmacist can help you manage your migraine headaches.  Some insurance companies only allow certain triptans for headache.  Your Thompson Pharmacist can guide through your challenges with headache management with expert advice.

It is important to keep a headache diary that tells how often, how severe what might trigger your migraines and what gives you relief.  Go Ahead and ASK… at Thompson Pharmacy it; ALL for YOU!!