Triptans The Newest Family of Drugs For Migraines

These drugs are used to relieve migraine headaches, with or without aura, in adults. Triptans are thought to work by narrowing swollen blood vessels in the brain that, when overdilated, cause migraine pain.

Triptans do not prevent or cure migraines, do not reduce frequency of migraines, and are not recommended for migraines described as basilar or hemiplegic. About 25% of patients do not respond to any of the triptans. Triptans should only be used after determining that acetaminophen (TYLENOL), or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (MOTRIN, ADVIL) fail to work, or cannot be taken due to allergies.

In 2005, an article in the French publication Prescrire Int. looked at the use of nasal sumitriptan for adolescents with migraine. The article stated that there was too little benefit and that there was an unfavorable risk-benefit balance in adolescents. According to the article, clinical assessment of sumatriptan in adolescents is inadequate.  All trials were placebo controlled. There were no trials comparing sumatriptan with non specific analgesics such as acetaminophen and non steroidal anti-inflammatory drugs.

The first triptan to be approved was sumitriptan (IMITREX), first marketed in 1995. As of this writing seven triptans are available on the U.S. market. Triptans are also called serotonin stimulators. Safety, effectiveness, and adverse effects among triptans are similar. Triptan symptoms of tingling, numbness, tightness in the chest and neck, and a sensation of warmth are common adverse effects of this drug family. About 20% of patients treated with triptans experience these chest symptoms. Other common adverse effects include dizziness, dry mouth, fatigue, nausea, and skeletal pain. Generally, higher doses lead to more adverse effects. Long-term use may affect your eyesight. Overuse may lead to withdrawal.

The Food and Drug Administration (FDA) issued a public health advisory on July 19, 2006, warning consumers about the possibility of life-threatening reactions — such as nausea, changes in blood pressure or hallucinations — that may be caused by the interaction of triptans and certain antidepressants.

When triptans are taken in combination with antidepressants known as selective serotonin reuptake  inhibitors (SSRIs) or selective serotonin/norepinephrine reuptake inhibitors (SNRIs), a condition called serotonin syndrome may result.
Serotonin syndrome develops when the body is exposed to too much of the naturally occurring chemical serotonin. Serotonin is found in the brain, blood and gastrointestinal tract. The combination of triptans, SSRIs and SNRIs can increase serotonin to extremely high levels that could result in serotonin syndrome.

The following are the symptoms that may be seen with the serotonin syndrome:

• restlessness
• hallucinations
• loss of coordination
• rapid heartbeat
• rapid changes in blood pressure
• increased body temperature
• overactive reflexes
• nausea, vomiting and diarrhea

The main differences among triptans include how fast the drug is absorbed and how long it stays in the body. Generally, the faster a triptan is absorbed, the more quickly it may relieve the migraine, but the shorter the time it remains in the body. Rizatriptan acts quickly, but migraines may recur not long after. Frovatriptan and naratriptan do not act as quickly as other triptans, but stay longer in the body, so migraines may be less apt to recur.

Drug interactions may differ among triptans. Only the injectable form of sumatriptan is also approved to treat cluster headaches. An advantage of sumatriptan is longer clinical experience. The amount of published information available also differs among triptans. This prompted The Lancet, a leading medical journal, to comment that what little information was available about frovatriptan suggested it may be less effective than other triptans.

Older people who use frovatriptan may need a lower dose. Other differences among triptans include the routes of administration available. Injections and nasal sprays are more quickly absorbed. Disintegrating tablets and wafers are convenient, dissolving quickly on the tongue, but more expensive. People with phenylketonuria should not take these rapid forms of rizatriptan and zolmitriptan, as these contain aspartame.

Serious adverse cardiac events, including acute myocardial infarction, have been reported within a few hours following administration of almotriptan.

Almotriptan can cause a spasm-like contraction of blood vessels in the heart; at least one of these events occurred in a patient with no cardiac history and with documented absence of coronary artery disease.  Because of the close proximity of the events to use of almotriptan, a causal relationship cannot be excluded.

Serious cardiovascular events have been reported in association with the use of almotriptan.  The uncontrolled nature of postmarketing surveillance, however, makes it impossible to definitively determine the proportion of the reported cases that were actually caused by almotriptan or to reliably assess causation in individual cases.

The Swedish Medical Products Agency has reported 5 cases of myocardial infarction with the use of sumatriptan.

If you have severe liver problems, do not take almotriptan, eletriptan, frovatriptan, or naratriptan. Even if you have less severe liver problems, be cautious of taking any triptan. People who have severe kidney problems should not take naratriptan. People on dialysis should be cautious of using rizatriptan or sumatriptan. If you have moderate or mild kidney problems, your doctor may prescribe a lower dose of naratriptan.

People whose high blood pressure is not controlled should not take triptans. If your blood pressure is controlled, be aware that triptans may cause your blood pressure to rise. None of the triptans are approved by the FDA for use in children under the age of 18 years.