II. Class

III. Indications

IV. Contraindications

  1. Coronary Artery Disease
  2. Uncontrolled Hypertension
  3. Basilar Artery Migraine
  4. Familial Hemiplegic Migraine
  5. Ischemic Cerebrovascular Accident
  6. Prinzmetal's Angina
  7. Pregnancy
  8. Concurrent Medication use (absolute contraindications)
    1. MAO inhibitor use
    2. Ergotamine use in prior 24 hours

V. Controversial cohorts in whom Triptan use is thought safe

  1. Controlled Diabetes Mellitus
  2. Controlled Hypertension
  3. Controlled Hyperlipidemia
  4. Postmenopausal women
  5. Men over age 40 years

VI. Drug Interactions

  1. See absolute contraindications above
    1. Ergotamine
    2. MAO inhibitors
  2. Lithium
  3. Selective Serotonin Reuptake Inhibitor (SSRI)
    1. Risk of Serotonin Syndrome
  4. Propranolol with Rizatriptan
    1. Requires reducing Rizatriptan dose

VII. Dosing: General

  1. Screen for cardiac disease before use!
  2. Limit to no more than twice weekly

VIII. Dosing: Sumatriptan (Imitrex)

  1. Subcutaneous Sumatriptan
    1. Initial: 6 mg SC
    2. Repeat in 12 hours prn
    3. Maximum: 12 mg/day
    4. Even generic dosing approaches $100/dose
  2. Oral Sumatriptan
    1. Initial: 25 mg PO
    2. Repeat 25 to 100 mg PO every 2 hours prn
    3. Maximum: 300 mg/day
    4. Generic dosing may be as low as $3/dose
  3. Intranasal Sumatriptan
    1. Initial: 5, 10 or 20 mg intranasal
      1. Dose responsive (20 mg more effective)
    2. Repeat after 2 hours prn
    3. Maximum: 40 mg/day
    4. Safety of use in over 4 Headaches per month not known
  4. Treximet (combination with Naproxen)
    1. Contains Sumatriptan 85 mg with Naproxen 500 mg
    2. Released as Sumatriptan becomes generically available
    3. Cheaper to purchase generic Sumatriptan (when available) and Naproxen separately
  5. Other Sumatriptan formulations
    1. Zecurity patch
      1. Removed from market 2016 due to serious adverse effects including burns
      2. http://www.fda.gov/Drugs/DrugSafety/ucm504588.htm

IX. Dosing: Rizatriptan (Maxalt, Maxalt MLT)

  1. Initial: 5 to 10 mg PO (MLT form is lingual)
  2. Repeat dose in 2 hours
  3. Maximum: 30 mg in 24 hours

X. Dosing: Naratriptan (Amerge)

  1. Initial: 1 to 2.5 mg PO
  2. Repeat in 4 hours
  3. Maximum: 5 mg in 24 hours

XI. Dosing: Zolmitriptan (Zomig)

  1. Oral
    1. Initial: 1.25 to 2.5 mg PO
    2. Repeat dose every 2 hours
    3. Maximum: 10 mg in 24 hours
  2. Intranasal
    1. Dose: 5 mg spray (single dose unit)
    2. Onset: 15 minutes (faster than oral preparations)

XII. Dosing: Eletriptan (Relpax)

  1. Initial: 20 to 40 mg PO
  2. May repeat dose in 2 hours
  3. Maximum: 40 mg/dose or 80 mg/day

XIII. Dosing: Almotriptan (Axert)

  1. Initial: 6.25 to 12.5 mg PO; may repeat in 2 hours
  2. Maximum: 2 doses in 24 hours

XIV. Dosing: Frovatriptan (Frova)

  1. Initial dosing: 2.5 mg PO; may repeat in 2 hours
  2. Maximum dose: 7.5 mg per day

XV. Adverse reactions

  1. Tingling, Flushing or burning sensation at injection
  2. Heavy chest
    1. Generally benign in low risk populations
    2. Risk of Coronary Artery Disease exacerbation
  3. Terrible taste with intranasal preparations

XVI. Efficacy: Sumatriptan

  1. Efficacy dependent on mode of drug delivery
    1. Subcutaneous effective in 80% of patients
    2. Intranasal effective in 70% of patients
    3. Oral effective in 60% of patients
  2. Oral form does not prevent Migraine recurrence
    1. Rapoport (1995) Neurology 45:1505-9 [PubMed]

XVII. Efficacy

  1. Most effective oral agents (c/w Imitrex 100 mg PO)
    1. Rizatriptan (Maxalt) 10 mg PO
    2. Eletriptan (Relpax) 80 mg PO
    3. Almotriptan (Axert) 12.5 mg PO (least side effects)
  2. References
    1. Ferrari (2001) Lancet 358:1668-75 [PubMed]

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Cost: Medications

sumatriptan (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
SUMATRIPTAN 20 MG NASAL SPRAY Generic $45.17 each
SUMATRIPTAN 4 MG/0.5 ML INJECT Generic $176.38 per ml
SUMATRIPTAN 5 MG NASAL SPRAY Generic $45.58 each
SUMATRIPTAN 6 MG/0.5 ML INJECT Generic $140.23 per ml
SUMATRIPTAN 6 MG/0.5 ML REFILL Generic $115.94 per ml
SUMATRIPTAN 6 MG/0.5 ML VIAL Generic $58.94 per ml
SUMATRIPTAN SUCC 100 MG TABLET Generic $0.71 each
SUMATRIPTAN SUCC 25 MG TABLET Generic $0.81 each
SUMATRIPTAN SUCC 50 MG TABLET Generic $0.74 each
imitrex (on 1/1/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
IMITREX 100 MG TABLET Generic $0.71 each
IMITREX 20 MG NASAL SPRAY Generic $45.17 each
IMITREX 5 MG NASAL SPRAY Generic $45.58 each
IMITREX 50 MG TABLET Generic $0.74 each
IMITREX 6 MG/0.5 ML CARTRIDGES $346.36 per ml
IMITREX 6 MG/0.5 ML PEN INJECT Generic $140.23 per ml
rizatriptan (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
RIZATRIPTAN 10 MG ODT Generic $1.15 each
RIZATRIPTAN 10 MG TABLET Generic $1.00 each
RIZATRIPTAN 5 MG ODT Generic $1.08 each
RIZATRIPTAN 5 MG TABLET Generic $1.02 each
maxalt (on 6/23/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
MAXALT 10 MG TABLET Generic $1.00 each
MAXALT MLT 10 MG TABLET Generic $1.15 each
zolmitriptan (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
ZOLMITRIPTAN 2.5 MG ODT Generic $8.04 each
ZOLMITRIPTAN 2.5 MG TABLET Generic $7.46 each
ZOLMITRIPTAN 5 MG ODT Generic $8.71 each
ZOLMITRIPTAN 5 MG TABLET Generic $8.26 each
zomig (on 10/1/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
ZOMIG 2.5 MG TABLET Generic $7.46 each
ZOMIG 5 MG NASAL SPRAY $59.12 each
ZOMIG 5 MG TABLET Generic $8.26 each
ZOMIG ZMT 2.5 MG TABLET Generic $8.04 each
ZOMIG ZMT 5 MG TABLET Generic $8.71 each
naratriptan (on 11/23/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
NARATRIPTAN HCL 1 MG TABLET Generic $5.35 each
NARATRIPTAN HCL 2.5 MG TABLET Generic $3.21 each
amerge (on 1/1/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
AMERGE 2.5 MG TABLET Generic $3.21 each
relpax (on 6/1/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
RELPAX 20 MG TABLET $54.44 each
RELPAX 40 MG TABLET $54.56 each
frovatriptan (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
FROVATRIPTAN SUCC 2.5 MG TAB Generic $38.07 each
frova (on 2/22/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
FROVA 2.5 MG TABLET Generic $38.07 each
treximet (on 3/22/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
TREXIMET 85-500 MG TABLET $85.63 each

Ontology: Sumatriptan (C0075632)

Definition (NCI) A sulfonamide triptan with vasoconstrictor activity. Sumatriptan selectively binds to and activates serotonin 5-HT1D receptors in the central nervous system (CNS), thereby constricting cerebral blood vessels. This may lead to a relief in pain from vascular headaches. Sumatriptan may also relieve vascular headaches by decreasing the release of vasoactive neuropeptides from perivascular trigeminal axons in the dura mater during a migraine, by reducing extravasation of plasma proteins, and by decreasing the release of other mediators of inflammation from the trigeminal nerve.
Definition (CSP) sulfonamide serotonin agonist and vasoconstrictor that acts selectively at 5HT1 receptors; frequently used in treating migraines.
Definition (MSH) A serotonin agonist that acts selectively at 5HT1 receptors. It is used in the treatment of MIGRAINE DISORDERS.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D018170
SnomedCT 350311006, 395892000, 322822007
LNC LP28529-3, MTHU013332
English Sumatriptan, 3-(2-(Dimethylamino)ethyl)-N-methyl-1H-indole-5-methanesulfonamide, 1H-Indole-5-methanesulfonamide, 3-(2-(dimethylamino)ethyl)-N-methyl-, sumatriptan, sumatriptan (medication), selective 5-HT receptor agonists sumatriptan, SUMATRIPTAN, Sumatriptan [Chemical/Ingredient], SUMAtriptan, Sumatriptan product, Sumatriptan (substance), Sumatriptan product (product), Sumatriptan product (substance)
Swedish Sumatriptan
Czech sumatriptan
Finnish Sumatriptaani
Russian SAMATRIPTAN, SUMATRIPTAN, САМАТРИПТАН, СУМАТРИПТАН
Japanese コハク酸スマトリプタン, スマトリプタン, イミグラン
Spanish sumatriptán (producto), sumatriptán, producto (producto), sumatriptán, sumatriptán, producto, sumatriptano (sustancia), sumatriptano, Sumatriptán
Polish Sumatryptan
French Sumatriptan
German Sumatriptan
Italian Sumatriptan
Portuguese Sumatriptana

Ontology: rizatriptan (C0297635)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C093622
SnomedCT 363573000, 108411001
English N,N-dimethyl-2-(5-(1,2,4-triazol-1-ylmethyl)-1H-indole-3-yl)ethylamine, rizatriptan, Rizatriptan product, rizatriptan [Chemical/Ingredient], RIZATRIPTAN, Rizatriptan, Rizatriptan (product), Rizatriptan (substance), Rizatriptan product (substance)
Spanish rizatriptán (producto), rizatriptano (producto), rizatriptano, rizatriptano (sustancia), rizatriptán (sustancia), rizatriptán

Ontology: zolmitriptan (C0528166)

Definition (NCI) A member of the triptan class agents with anti-migraine property. Zolmitriptan selectively binds to and activates serotonin (5-HT) 1B expressed in intracranial arteries and 5_HT 1D receptors located on peripheral trigeminal sensory nerve terminals in the meninges and central terminals in brain stem sensory nuclei. Receptor binding results in constriction of cranial vessels, reduction of the vessel pulsation and inhibition of nociceptive transmission, thereby providing relief of migraine headaches. Zolmitriptan may also relief migraine headaches by inhibition pro-inflammatory neuropeptide release.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C089750
SnomedCT 363582006, 108406003
LNC LP31829-2, MTHU016110
English 4-((3-(2-(dimethylamino)ethyl)-1H-indol-5-yl)methyl)-2-oxazolidinone, 2-Oxazolidinone, 4-((3-(2-(dimethylamino)ethyl)-1H-indol-5-yl)methyl)-,(S)-, zolmitriptan, Zolmitriptan product, zolmitriptan (medication), selective 5-HT receptor agonists zolmitriptan, ZOLMITRIPTAN, zolmitriptan [Chemical/Ingredient], ZOLMitriptan, Zolmitriptan, Zolmitriptan (product), Zolmitriptan (substance), Zolmitriptan product (substance)
Spanish zolmitriptano, zolmitriptano (producto), zolmitriptán (producto), zolmitriptano (sustancia), zolmitriptán (sustancia), zolmitriptán

Ontology: naratriptan (C0540623)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C106783
SnomedCT 363571003, 108408002
English N-methyl-3-(1-methyl-4-piperidinyl)-1H-indole-5-ethanesulfonamide, naratriptan, Naratriptan product, naratriptan [Chemical/Ingredient], NARATRIPTAN, Naratriptan, Naratriptan (product), Naratriptan (substance), Naratriptan product (substance)
Spanish naratriptano, naratriptano (producto), naratriptán (producto), naratriptano (sustancia), naratriptán (sustancia), naratriptán

Ontology: Zomig (C0594405)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C089750
English Zomig, zomig, AscoTop, Astra brand of zolmitriptan, AstraZeneca brand of zolmitriptan, Zeneca brand of zolmitriptan, Zomigoro

Ontology: Amerge (C0594660)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C106783
English amerge, Naramig, Amerge, Glaxo Wellcome brand of naratriptan hydrochloride, GlaxoSmithKline brand of naratriptan hydrochloride, Schwarz brand of naratriptan hydrochloride

Ontology: Imitrex (C0721044)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
English Imitrex, imitrex

Ontology: Maxalt (C0721599)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C093622
English Maxalt, maxalt

Ontology: frovatriptan (C0754647)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C108128
SnomedCT 408042004, 370215003, 411990007
English 3-methylamino-6-carboxamido-1,2,3,4-tetrahydrocarbazole, frovatriptan, frovatriptan [Chemical/Ingredient], Frovatriptan (product), FROVATRIPTAN, Frovatriptan product (product), Frovatriptan product, Frovatriptan, Frovatriptan (substance)
Spanish frovatriptán (producto), producto con frovatriptano (producto), frovatriptán, producto con frovatriptano, frovatriptan (producto), frovatriptan, frovatriptan (sustancia)

Ontology: eletriptan (C0759933)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C115647
SnomedCT 395255007, 410843003
English eletriptan, eletriptan [Chemical/Ingredient], ELETRIPTAN, Eletriptan (product), Eletriptan, Eletriptan (substance)
Spanish eletriptán (producto), eletriptán, eletriptán (sustancia)

Ontology: Frova (C1099778)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C108128
English Frova, frova, Elan brand of frovatriptan succinate, UCB brand of frovatriptan succinate

Ontology: Relpax (C1171655)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH C115647
English Relpax, relpax, Mack brand of eletriptan hydrobromide, Pfizer brand of eletriptan hydrobromide

Ontology: Triptans (C1567966)

Definition (MSH) Derivatives of TRYPTAMINES that are SEROTONIN RECEPTOR AGONISTS acting at 5-HT1 RECEPTORS. Some are used to treat MIGRAINE DISORDERS.
Concepts Organic Chemical (T109) , Pharmacologic Substance (T121)
MSH D014363
French Triptans
Czech triptany
Norwegian Triptaner
English Triptans