Migraine medication: What are the differences between the triptans?

Drugs known as triptans can relieve migraine symptoms. There are differences among the triptans, for instance in what form they are used or in how quickly there is an effect. It is not certain whether any particular triptan has fewer adverse effects than others.

Migraines are headaches that start suddenly. The pain is typically strong and sudden, usually on only one side of the head. Migraines may last between four hours and three days and are often accompanied by nausea and vomiting. Some people feel unusually sensitive to light and noise during a migraine attack. You can read more about the different types of headaches and the signs that a headache is a migraine here.

A lot of people are affected by migraines, and they are more common in women than men. In Germany, 14 out of 100 women and 8 out of 100 men have migraines. More than 1 out of every 4 women will have at least one migraine at some time in their lives (25%). You can read more about migraines in adults, children and young people here.

Migraines can affect people’s quality of life a lot. Migraine medication can help, but people also need to be careful with medications they use for their headaches. Up to 2% of people have a chronic headache that never goes away, caused by overuse of headache medication.

Medicine choices for migraine and the triptans

In general, migraine is treated with the same drugs that are used for other headaches. Some examples include acetylsalicylic acid (ASA), ibuprofen and paracetamol (also known as acetaminophen). People who have a lot of nausea with their migraines also sometimes try anti-nausea drugs, or a migraine drug that includes both painkillers and anti-nausea medication. You can read more about these and other medications for migraine attacks here.

There is also a group of drugs known as “triptans”. Triptans are especially for migraine treatment, and are not intended for long-term use to prevent migraines. The triptans aim to relieve pain, nausea and light sensitivity at the same time. All have been shown to help more than half of people with migraines, but they are not suitable for people who have cardiovascular disease.

At present there are seven different triptans: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan and zolmitriptan. Zolmitriptan and sumatriptan are the most commonly used triptans in Germany and have been available the longest. Some of these drugs come in different forms, for example as a tablet, nose spray, suppository, injection or a pill to be placed under the tongue. Triptans are prescription-only; only naratriptan is available without a prescription in Germany.

Although the triptans are one class of drugs, there are several differences between them. They come in very different doses for example. Zolmitriptan tablets have 2.5 or 5 mg of triptan in them, while sumatriptan tablets have 50 to 100 mg in them. This is because of slight chemical differences between the drugs. The different triptans also work a little differently from one another. For example, some of them start working more quickly than others, while for others the effect of the dose lasts for longer. This means that if one triptan does not help an individual person with their migraine as much as they would like, it could be worth trying another.

The statutory health insurance funds in Germany only cover the costs for triptans up to a fixed amount (in German: Festbetrag). Any extra costs for more expensive triptans will usually have to be paid for out-of-pocket.

Evidence from trials comparing different triptans

Researchers from the Oregon Health and Science University in the United States wanted to find out whether there are differences between the triptans so that people with migraine can choose the triptan that suits their needs best. They found and analyzed 17 trials that compared two or more triptans with each other. This means that one group of volunteers was given one triptan, while another group took a different triptan. The participants were randomly assigned to one of the two groups. Sometimes, the drugs were re-packaged that all looked the same, to make sure that no one knew which triptan they were taking. In total, more than 23,000 people with migraines took part in these trials.

Most of the trials compared how well the triptans were able to relieve or get rid of migraine symptoms after a specific amount of time. They usually looked at improvement of symptoms two hours after participants had taken one of the drugs. Not all of the triptans were compared with each other directly, though. The only trials that had results from which the researchers could draw conclusions had studied the tablet form of the triptan.

• There is evidence that rizatriptan could be more effective than naratriptan. A comparative trial showed that by using rizatriptan, more people were free of symptoms than by using naratriptan.
• Rizatriptan also seems to be somewhat more effective than zolmitriptan – but the zolmitriptan in the comparative trial was used in the lowest recommended dose.
• Eletriptan is possibly more effective in the short term than naratriptan.
• The other triptans seem to be either equally effective or it was not possible to say anything about their advantages and disadvantages because there were no trials or no trials of good quality.

The researchers also concluded that in these trials, the adverse effects did not differ considerably between the various triptans. The adverse effects reported in the trials include drowsiness, weakness, mild nausea and abnormal sensations such as pins and needles, warmth or chills. In rare cases triptans can affect the heart and circulation, for example by raising blood pressure. This means that triptans are not suitable for people who have coronary artery disease (narrowing of the arteries).

Other researchers have concluded that triptans might be less likely to lead to medication overuse headache than other migraine medications. You can read more about medications for migraines here.

Author: Institute for Quality and Efficiency in Health Care (IQWiG)

© IQWiG (Institute for Quality and Efficiency in Health Care)