Practice Therapeutics

Triptans for symptomatic treatment of migraine headache

BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g2285 (Published 07 April 2014) Cite this as: BMJ 2014;348:g2285
  1. Tamara Pringsheim, assistant professor1,
  2. Werner J Becker, professor2
  1. 1Department of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences, University of Calgary, Calgary, Alberta Children’s Hospital, Calgary, AB, Canada T3B 6A8
  2. 2Department of Clinical Neurosciences, University of Calgary, Calgary, Foothills Medical Centre, Calgary, AB, Canada
  1. Correspondence to: T Pringsheim tmprings{at}ucalgary.ca

Case scenario

A 30 year old woman has debilitating, pulsating right sided headaches up to twice a month for several years. Her pain builds up rapidly and usually lasts 24 hours. She has to lie down during episodes, which are associated with sensitivity to light, severe nausea, and occasional vomiting. Over the counter analgesics such as ibuprofen or paracetamol were initially helpful in relieving pain, but not recently. She asks if any treatments may help with her headaches and allow her to return to her usual activities sooner.

What are triptans?

Migraine is a common clinical problem, with a global prevalence of 14.7%, and is the eighth most common cause globally of years lived with disability.1 The triptans are selective 5-hydroxytryptamine (5HT) receptor agonists, with high affinity for the 5HT1B and 5HT1D receptors. 5HT1B receptors are on smooth muscle cells of blood vessels and cause vasoconstriction when stimulated. 5HT1D receptors lie on perivascular trigeminal nerve terminals and in the dorsal horn, and their stimulation blocks the release of vasoactive peptides from trigeminal neurones and the release of neurotransmitters in the dorsal horn that convey nociceptive information to the thalamus.2 Seven triptans are commercially available—sumatriptan, naratriptan, zolmitriptan, rizatriptan, eletriptan, frovatriptan, and almotriptan—with minor pharmacokinetic and pharmacodynamic differences between them. Sumatriptan was the first commercially available triptan and has been used in clinical practice since the early 1990s. Several different vehicle delivery systems are available for these drugs, including a subcutaneous injection, nasal spray, rapid melt tablet, and oral tablet (see table for formulations available, dosages, onset of action, number needed to treat, and drug interactions).

View this table:

Triptans: pharmacokinetics and NNT for 2 hour pain-free response*†

How well do triptans work?

Three systematic reviews of sumatriptan for the acute treatment of migraine were published in the Cochrane Library in 2012. They evaluated the oral tablet,5 …

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