Richard B. Lipton, MD: Choosing a therapy in any condition obviously involves weighing efficacy and safety for migraine. Different treatment options have different attributes. Generally speaking, all the available drugs are quite safe but differ in tolerability. The injectable formulation of sumatriptan, for example, which is available in several doses, has a rapid onset of action and is quite effective; however, it produces more minor adverse effects than sumatriptan through other routes. You’re more likely with injectable sumatriptan to feel flushing and tingling; in some rare instances, a chest-pressure sensation, which is frightening in a drug that constricts blood vessels and has a small amount of cardiovascular liability.
The other issue we talk about when beginning treatment is the importance of physicians to recognize, when we see patients for migraine in primary care or specialty care settings, if the patient is already using some acute treatment, which is a frequent occurrence. It’s important to determine what the patient is using and what they’ve used in the past, as well as what their unmet treatment needs may be. If a patient’s unmet treatment need is quick effectiveness, it is important to consider an injection or nasal spray. If a patient wants a drug that’s likely to deliver greater tolerability, there are 2 triptans that are more tolerable than the others: naratriptan and almotriptan, which are both great choices.
If the patient’s problem is the acute treatment—it works quickly but their headache comes back every 2 to 24 hours thereafter—that’s a phenomenon called “headache relapse.” For these patients, it might be best to give a drug with a longer half-life such as eletriptan.
The patients also have a difference of preference in terms of efficacy-versus-toxicity—the speed with which the drug begins to work, versus the adverse effects associated. Knowing the alternatives and matching the treatment to the patient’s treatment needs and experience is essential to getting them the right treatment.
Stephen Silberstein, MD: Many of the adverse effects associated with triptans are distinct to the individual triptan. If, for example, sumatriptan injectables have more adverse effects than oral medications, and some of the other triptans like naratriptan have fewer adverse effects, you can switch from one to the other, and from injection to oral tablet, to figure out which treatment is the best option. Many people take triptan in combination with a nonsteroidal, receiving better results and perhaps fewer adverse effects.