Best Use of Triptans for Migraine

Standard dose triptans effectively relieve migraine headaches better than ergots, and most triptans are associated with equal or better outcomes compared with non-steroidal anti-inflammatory drugs (NSAIDs), aspirin, and acetaminophen, according to the results of a new systematic review. What’s more, the use of triptans in combination with aspirin or acetaminophen, or alternative modes of administration such as injectables, may lead to slightly better outcomes than standard doses of triptans.

Triptans are considered the first-line therapy for many patients with moderate to severe migraine. Canadian researchers conducted a systematic review and network meta-analysis to examine the evidence for the efficacy, effectiveness, and safety of triptans, alone or in combination with other drugs, for acute treatment of migraines compared with other triptan agents, NSAIDs, acetylsalicylic acid (ASA), acetaminophen, ergots, opioids, or anti-emetics.

Their review included 133 randomized controlled trials published between 1991 and 2012. Most were large, multicenter studies conducted in a variety of countries worldwide, and often across many different countries.

The results shows that standard dose triptans relieved headaches within 2 hours in up to three-quarters of patients, and 2-hour sustained freedom from pain was achieved for up to half of patients. Standard dose triptans provided sustained headache relief at 24 hours in up to half of patients, and sustained freedom from pain in up to one-third of patients. Up to one-third of patients needed to use rescue medications.

“Our findings align with those reported in other systematic reviews, although the majority of other reviews only report estimates of relative effect for standard dose triptans,” the authors state.

For 2-hour headache relief, standard dose triptan achieved better outcomes (42-76% response) than ergots (38%); equal or better outcomes than NSAIDs, ASA, and acetaminophen (46-52%); and equal or slightly worse outcomes than combination therapy (62-80%). These findings align with general recommendations for the routine use of triptans, NSAIDs, ASA, and acetaminophen, but not ergots, in the acute management of migraine, they note.

Among individual triptans, sumatriptan subcutaneous injection, rizatriptan ODT, zolmitriptan ODT, and eletriptan tablets were associated with the most favorable outcomes. Their analysis suggests that “the majority of triptans, except frovatriptan and naratriptan, deliver similar pain relief in the acute management of migraines,” they state.

A companion pharmacoeconomic report shows that the use of less costly generic triptans, such as sumatriptan, could significantly reduce total expenditure on triptans.

The authors note that the studies were not sufficiently powered to measure differences in long-term complications or adverse events. “Future research is needed in assessing the long-term use of triptans in the acute management of recurrent migraines,” they state.

In conclusion, the authors note that “triptans were found to be efficacious for the treatment of acute migraine. Use of triptans in combination with aspirin or acetaminophen, or using different modes of administration such as injection, was associated with slightly better results than standard dose triptan tablets.”