Triptan

Aka: Triptan, Sumatriptan, Imitrex, Rizatriptan, Maxalt, Zolmitriptan, Zomig, Naratriptan, Amerge, Eletriptan, Relpax, Frovatriptan, Frova, Treximet

1. Class
   1. Serotonin Agonists
2. Indications
   1. Migraine Abortive Treatment
3. Contraindications
   1. Coronary Artery Disease
   2. Uncontrolled Hypertension
   3. Basilar ArteryMigraine
   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
4. 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
5. 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
6. Dosing: General
   1. Screen for cardiac disease before use!
   2. Limit to no more than twice weekly
7. Dosing: Sumatriptan (Imitrex)
   1. Subcutaneous Sumatriptan
      1. Initial: 6 mg SC
      2. Repeat in 12 hours prn
      3. Maximum: 12 mg/day
   2. Oral Sumatriptan
      1. Initial: 25 mg PO
      2. Repeat 25 to 100 mg PO every 2 hours prn
      3. Maximum: 300 mg/day
   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
8. 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
9. Dosing: Naratriptan (Amerge)
   1. Initial: 1 to 2.5 mg PO
   2. Repeat in 4 hours
   3. Maximum: 5 mg in 24 hours
10. 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)
11. 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
12. Dosing: Almotriptan (Axert)
    1. Initial: 6.25 to 12.5 mg PO; may repeat in 2 hours
    2. Maximum: 2 doses in 24 hours
13. Dosing: Frovatriptan (Frova)
    1. Initial dosing: 2.5 mg PO; may repeat in 2 hours
    2. Maximum dose: 7.5 mg per day
14. 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
15. 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
16. 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
17. References
    1. Jamieson (2002) Am J Med 112:138