Magazine article Clinical Psychiatry News

Get It Right the First Time with High-Dose Triptan: In Patients with Acute Migraine, the Greater Chance of Improvement Offsets the Risk of Adverse Events

Magazine article Clinical Psychiatry News

Get It Right the First Time with High-Dose Triptan: In Patients with Acute Migraine, the Greater Chance of Improvement Offsets the Risk of Adverse Events

Article excerpt

SCOTTSDALE, ARIZ. -- When it comes to triptan use in treatment of acute migraine, consider the maxim: Go big or stay home.

A high dose of a given triptan may be associated with an elevated risk for side effects; however, it also is more likely to be effective. Patients who do not respond to a lower dose given in the hope of avoiding adverse events are not going to come back to give the drug a second chance at a higher dose, Dr. Lawrence C. Newman said at a symposium sponsored by the American Headache Society.

"Studies generally show that the higher dose ranges are more effective for the trip-tans. We want to get treatment right the first time," Dr. Newman said. Underdosing, he added, might cause a lack of efficacy and drive a patient to discontinue therapy or refuse another migraine-specific medication in the future.

A patient who experiences an adverse event, which is more likely at a high dose, will never take a triptan again, a meeting attendee observed. "I respect your opinion, but you are blurring the line between a preventive and acute medication," Dr. Newman replied. "We find from acute studies that the higher doses are more effective. If I've had a patient try a medication at low dose for three attacks, and tell them I want to try the same medication for the next three attacks, they say no."

Dr. Newman is director of the Headache Institute, St. Luke's--Roosevelt Hospital Center, New York City, and a consultant, adviser, and/or a member of the speakers' bureau for triptan manufacturers Glaxo-SmithKline, Endo Pharmaceuticals, Pfizer Inc., Merck & Co., and Ortho-McNeil Inc.

Each triptan is available in different dosages, making it easy to reduce the dose if a patient experiences an adverse effect, Dr. Newman said. "Studies generally show ... the side-effect profile does not differ significantly between the higher and lower doses.

There are currently seven triptans on the market, available in a number of formulations. All are available in tablet form, and some are available also as nasal sprays (sumatriptan, zolmitriptan), dissolvable wafers taken orally (rizatriptan, zolmitriptan), or injections (sumatriptan).

If headaches recur, treat attacks earlier, increase the dose, switch triptans, particularly to naratriptan or frovatriptan, add an NSAID, or switch to dihydroergotamine mesylate, Dr. Newman suggested.

"Do not give up on the triptan class because one does not work. …

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