Comparison of Triptans

TRIPTANS. Contraindications include ischemic or vasospastic heart disease, history of stroke or transient ischemic attack (TIA), cardiac arrhythmias, uncontrolled hypertension, peripheral vascular disease, ischemic bowel disease, other triptans or ergot derivatives within 24 hrs, and history of hemiplegic or basilar migraines (not a complete list). Number needed to treat (NNT) is ~5 for oral sumatriptan.² Consider injection or nasal spray formulations for patients with severe nausea and vomiting, migraines that quickly intensify, or patients who awaken with migraine.⁵

Almotriptan oral tablet
(Axert [no longer available], generics)

$2.54/12.5 mg

6.25 to 12.5 mg (6.25 mg in mild to moderate liver impairment or severe kidney impairment). May repeat after 2 hrs. Max daily dose 25 mg (12.5 mg in mild to moderate liver impairment or severe kidney impairment).

0.5 to 2 hrs⁷

3 to 4 hrs

70%

Better tolerated and better 2-hr efficacy than oral sumatriptan.⁴

Contraindicated in severe liver impairment.

Not contraindicated with MAOIs.

Eletriptan oral tablet (Relpax, generics)

$10.09/40 mg

20 to 40 mg. May repeat after 2 hrs. Max daily dose 40 mg.

30 min⁸

4 hrs

50%

Better 2-hr efficacy and lower recurrence rate than oral sumatriptan.⁴

Contraindicated for use within 72 hrs of clarithromycin, itraconazole, ketoconazole, nelfinavir, and ritonavir (potent CYP3A4 inhibitors).

Contraindicated in severe liver impairment.

Not contraindicated with MAOIs.

Frovatriptan oral tablet (Frova, generics)

$13.50/2.5 mg

2.5 mg. May repeat after 4 hrs. Max daily dose 5 mg.

2 to 3 hrs⁷

26 hrs

20% to 30%

Longest half-life.

Better tolerated and lower recurrence rate than oral sumatriptan.⁴

Contraindicated in severe liver impairment.

Not contraindicated with MAOIs.

Naratriptan oral tablet
(Amerge, generics)

$6.64/2.5 mg

1 to 2.5 mg (start with 1 mg in mild or moderate kidney or liver impairment). May repeat once after 4 hrs. Max daily dose 5 mg (2 mg in mild or moderate kidney or liver impairment).

1 to 3 hrs⁷

5 to 8 hrs

~70%

Better tolerated than oral sumatriptan.⁴

Lower recurrence rate than oral sumatriptan.⁶

Contraindicated in severe kidney

(CrCl <15 mL/min) or severe liver impairment.

Not contraindicated with MAOIs.

Rizatriptan oral tablet
(Maxalt, generics)

Rizatriptan ODT (Maxalt RPD, generics)

$4/10 mg

5 to 10 mg (5 mg in hemodialysis, moderate liver impairment, or with propranolol). May repeat after 2 hrs. Max daily dose 20 mg (10 mg in hemodialysis, moderate liver impairment, or with propranolol).

0.5 to 2 hrs⁷

2 to 3 hrs

45%

Better 2-hr efficacy than oral sumatriptan.⁴

Orally disintegrating tablet has slower absorption than the oral tablet.

Contraindicated in severe liver impairment.

Contraindicated if MAOI used in the past two weeks.

Sumatriptan subcutaneous injection (Imitrex, generic)

$45.88/6 mg vial (Imitrex)
$38.37/6 mg pre-filled syringe

6 mg. May repeat after 1 hr. Max daily dose 12 mg.

10 to 15 min

2 hrs

96%

Fastest and most effective treatment, but has a higher rate of adverse effects.⁴

Contraindicated in severe liver impairment.

Contraindicated if MAOI used in the past two weeks.

Sumatriptan oral tablet
(Imitrex DF, generics)

$3.30/100 mg

50 or 100 mg. May repeat after 2 hrs. Max daily dose 200 mg.

30 min.

2 hrs

14%

Contraindicated in severe liver impairment. Not recommended in mild or moderate liver impairment.

Contraindicated if MAOI used in the past two weeks.

Sumatriptan nasal spray (Imitrex)

$17.91/20 mg

5, 10, or 20 mg. May repeat once after 2 hrs. Max daily dose 40 mg.

15 min

2 hrs

16%

Taste and nasal route not acceptable to some patients.¹

Contraindicated in severe liver impairment. Not recommended in mild or moderate liver impairment.

Contraindicated if MAOI used in the past two weeks.

Suvexx oral tablet
(sumatriptan 85 mg/naproxen 500 mg)

$10.41/tab

One tablet. May repeat after 2 hrs. Max daily dose two tablets.

NA

2.2 hrs (S)/
19.9 hrs (N)

14% (S)/
95% (N)

Sumatriptan 50 mg plus naproxen

500 mg taken separately may be just as effective.³

Triptan/NSAID combo more effective and lasts longer than either alone.³

Contraindicated in severe kidney impairment (CrCl <30 mL/min).

Contraindicated in moderate or severe liver impairment. Not recommended in mild liver impairment.

Contraindicated if MAOI used in the past two weeks.

Zolmitriptan oral tablet (Zomig, generics)

Zolmitriptan ODT
(Zomig-ZMT, generics)

$2.96/2.5 mg

2.5 mg (half tablet for moderate or severe liver impairment). May repeat after 2 hrs. Max daily dose 10 mg.

45 min⁷

2.5 to
3 hrs

40%

Zolmitriptan oral tablet 5 mg single dose is not much more effective than 2.5 mg, but has more adverse effects.

Contraindicated if MAOI used in the past two weeks.

Zolmitriptan nasal spray (Zomig)

$16/5 mg

2.5 to 5 mg. May repeat after 2 hrs. Max daily dose 10 mg.

15 min⁹

3 hrs

41%

Zolmitriptan 5 mg nasal spray is more effective than 2.5 mg oral tablet.

Taste and nasal route not acceptable to some patients.¹

Contraindicated if MAOI used in the past two weeks.