Prescriber 2010: 21(17) (5th September)

If sumatriptan 100 mg hasn’t done the trick for your patient’s migraines, which triptan should you try next?  Well…

  • If the problem was that it didn’t work, you can try rizatriptan 10 mg (Maxalt) or eletriptan 80 mg (Relpax), both of which show better efficacy.  Rizatriptan is likely to be your better bet of the two, as it also has better consistency, and eletriptan 80 mg has lower tolerability than rizatriptan 10 mg or sumatriptan 100 mg (which are similar to each other in tolerability).  Lower doses of eletriptan exist, but 40 mg is similar in efficacy to sumatriptan 100 mg & 20 mg is less effective.
  • If the problem is that it worked but the pain-free response didn’t last, consider Almotriptan 12.5 mg (Almogran), which has similar efficacy to Sumotriptan at 2 hours but better sustained pain-free response.  It also has better consistency (whatever that means) and better tolerability.
  • If it worked but the side-effects were a problem, then, as above, you can consider Almotriptan, or Eletriptan 20 mg (which has lower efficacy but better tolerability).  Also, there’s Naratriptan 2.5 mg, and, of course, Sumatriptan 25 mg (50 mg doses aren’t mentioned).
  • As for Zolmitriptan (2.5 mg or 5 mg), Eletriptan 40 mg, or Rizatriptan 5 mg, they all show pretty similar results to Sumatriptan 100 mg.

While on the subject of triptans, note that they should not be taken with premonitory symptoms/aura, but only when the headache starts, and the dose should only be repeated if the headache recurs after having cleared completely (don’t ask me why).  Note that uncontrolled hypertension, a history of CVA/TIA, or cardiovascular disease are all contraindications.  So is being under 12, although specialists will occasionally use them for children in that age group after all due thought and discussion, etc., etc.  12 – 17-year-olds can use Sumatriptan nasal spray.

On the subject of migraines, don’t forget lifestyle changes.  Eat regularly (try not to go for more than 4 hours during the day or 12 hours overnight without eating), avoid processed sugars/junk foods/fizzy dirnks as much as possible, minimise caffeine intake, drink 2 litres of water every day, take regular exercise and get regular sleep, consider work posture and lighting at work and make sure you take regular breaks, and consider how to minimise/best deal with life’s various stresses.  One useful piece of advice offered was that every headache sufferer should ‘put themselves first at least once every day’.

For migraine sufferers looking for natural prophylactics, the evidence seems promising – riboflavin (400 mg once daily, according to NICE), and butterbur have both been found to be helpful in reducing migraines.  Feverfew also seems to work but it’s not certain what the active ingredient is.  Magnesium also may be of benefit, but has a lot of side-effects.  Co-enzyme Q seemed promising in one study.

And, when using pharmaceutical options for prophylaxis, do remember the disadvantages of topiramate in women of childbearing age.  It’s an enzyme inducer with all the potential problems that causes with hormonal contraception, it’s been linked with an increased rate of oral clefts in babies exposed in utero, and the enzyme-inducing effect also means that women should be on 20 mg Vitamin K daily through the last month of pregnancy (as well as the 5 mg folic acid daily in the first trimester).


About Dr Sarah

I'm a GP with a husband and two young children.
This entry was posted in Migraine, Neurology, Pregnancy and Childbirth, Prescriber. Bookmark the permalink.

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