Magazine article Clinical Psychiatry News

Drug Update: Moderately Severe Migraine Headaches

Magazine article Clinical Psychiatry News

Drug Update: Moderately Severe Migraine Headaches

Article excerpt

Triptans have revolutionized the treatment of migraines. More formally known as selective serotonin receptor agonists, triptans are clearly the first class of drugs physicians should consider when treating most patients with migraine headaches that are moderate to severe. Analgesics and nonsteroidal anti-inflammatory drugs are the first-line treatment for patients with mild migraine headaches, and they also are a good first choice for more severe migraines. But by the time most patients seek medical help for moderately severe migraine headaches, they have usually already tried analgesics and NSAIDs on their own, without success.

Ergot derivatives are another option for moderately severe migraine headaches, but in general they're considered inferior to the triptans. Opiates are generally avoided except as a last resort.

The route of delivery can have a major impact on the treatment outcome. Since migraines are often accompanied by nausea and vomiting, oral formulations may not be best. The response rate to the nasal spray form of sumatriptan is similar to that of the oral form. This dosing route is often recommended for adolescents or patients who experience early-morning migraines. The major drawback of nasal sprays is that many patients complain of a bitter aftertaste. An injectable form of sumatriptan is also very effective but is less convenient.

Little clinical data exist to guide the choice of migraine treatment in women who are pregnant or breast-feeding. Avoid triptans and ergot derivatives, in these women. For women with severe, persistent, recurring migraines, narcotics and antiemetics may be used to relieve debilitating symptoms. Most pregnant migraineurs have a decrease in the frequency and intensity of their attacks. For breast-feeding women, one possible strategy is to pump breast milk shortly after dosing, then discard it and substitute formula for the next feeding.

In elderly patients, avoid triptans if heart disease is present. For most elderly patients, an analgesic or NSAID is adequate.

Comprehensive guidelines on managing acute migraine headaches were compiled by the American Academy of Neurology and the U.S. Headache Consortium in 2000, and were recently endorsed by the American College of Physicians--American Society of Internal Medicine. The guidelines can be found at


The major drug class for treating patients with more than mild migraine.
These drugs are probably more specific for treating migraine
pathophysiology than are the ergot derivatives, and they have fewer
adverse effects. They also relieve symptoms such as nausea, vomiting,
and sensitivity to light and sound. Study results suggest that about
two-thirds of patients respond to at least one drug from class. Patients
who fail to respond to one drug in class should try at least one other
before abandoning class. Landmark metaanalysis of trial results,
published last November (Lancet 358[9294]:1668-75, 2001), identified
small but important differences in efficacy among drugs in class. Safety
is similar among drugs in class, but tolerability differs. Route of
administration and experience with agent may also influence drug choice.
Some drugs in class have a longer serum half-life, suggesting a possible
difference in duration of action, but clinical relevance of this has not
been clearly shown.

Drug          Dose          Cost/Dose *

sumatriptan   25-100 mg     $16.49
 (Imitrex)    (oral)        (100 mg)

almotriptan   6.25-12.5 mg  $10.55

frovatriptan  2.5 mg        not available

naratriptan   1-2.5 mg      $18.46

rizatriptan   5-10 mg       $15.52

zolmitriptan  2.5-5 mg      $16.72
 (Zomig)                    (5 mg)

Drug          Comment **

sumatriptan   Triptan that's been on the U. … 
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