Triptans and other Abortives
WHAT ARE TRIPTANS?
Triptans are a class of medications used to treat acute migraine attack – that is, the part of your migraine attack where symptoms are most severe, for many people the headache part of the attack. Acute medications are designed to stop a migraine attack as the attack begins. Triptans cannot prevent your attack but can help alleviate the symptoms of migraine attacks such as pain, nausea, and sensitivity to light and sound.
It is important to understand that triptans are not pain relief, and should not be taken like pain relief medication. Triptans work by binding to receptors in the brain for the neurotransmitter serotonin, which works to diminish the swelling of blood vessels and reduce inflammation, which helps stop the migraine attack.
There are five triptans currently available in Australia, available as a tablet, wafer, nasal spray, or injection. All five are available on the PBS, but not all preparations are covered by the PBS. (So, for example, you can get the tablet affordably but not the injection.) They are:
- Sumatriptan (Imigran)
- Eletriptan (Relpax)
- Zolmitriptan (Zomig)
- Naratriptan (Naramig)
- Rizatriptan (Maxalt)
Discuss with your doctor which triptan may be best for you, but note that often you just have to try them all and find which one works best.
HOW DO I USE TRIPTANS?
Triptans work best when taken right at the beginning of the acute phase of the attack, or before the headache starts (if you get a headache). If you use your triptan more than 1 hour after the onset of headache, the research suggests it will not work as well, and may not work at all.
Ideally, you should:
- Take one dose just as the acute attack (headache or other most bothersome symptoms) starts, or if you know your migraine attack pattern well, just before it starts.
- If the attack goes away but comes back after two hours, you can take one more dose.
- DO NOT take more than 2 doses in 24 hours.
- DO NOT keep taking more doses as the attack progresses. This includes if your acute attack lasts more than 1 day; do not take triptans on the second or later day.
- DO NOT take triptans on more than 10 days per month as it is a risk for medication overuse headache.
Remember, triptans are not painkillers. They will not work for a headache that is not a migraine, and will not work for other kinds of pain. Taking more if it doesn’t work, as you might with painkillers, will not work.
WHO SHOULDN’T USE TRIPTANS?
Because triptans constrict blood vessels, therefore creating barriers to blood flow, they should be avoided by people with ischaemic heart disease – such as heart attack or angina – or other diseases of circulation. They should also be avoided by the elderly and those with significant liver problems, and you may want to discuss with your doctor if any of your other medications may clash with the triptan.
People who have had a stroke should also not use triptans, as the blood vessel constriction can increase stroke risk. There is some debate about people with migraine with aura, who are also at a higher risk of stroke, using triptans: discuss this with your neurologist. Generally, people with brainstem and hemiplegic migraine attacks will be cautioned not to use triptans because of the stroke risk.
New migraine abortive medications that do not constrict the blood vessels, and therefore will be safer for these people, are currently in development. They are called ditans (the first one will be called Reyvow), and gepants. Ditans also work with serotonin, but do not constrict blood vessels, and gepants are CGRP antagonists.