(30) Migraine

VIDEO

How Do Triptans Help Migraines

Triptans, their doses and delivery systems

 

My doctor has given me a triptan for my migraine. How does it work?

Your triptan will attach itself to very specific serotonin (5-HT) receptor sites in the brain and brainstem. By doing this it is able to counteract their effect and stop the migraine attack from developing further. This means that all the symptoms associated with your migraine go away.

Blood vessel I’m using a triptan now and find it very good but our doctor won’t let my son have any because he is only 16. Why is this?

Until recently, none of the triptans has been licensed for use under the age of 18.

What do I mean by ‘licensed’?

Once all the research and trials have been done to assess how effective and safe a drug is, an application is made to the European Medicines Evaluation Agency for licensing. The licence specifies at what dose and for what conditions a particular drug can be used as well as what age groups it can be used in.

Recently, however, a particular formulation of sumatriptan as an adolescent nasal spray has been launched. This has been designed for use by 12- to 18-year olds. Another triptan called zolmitriptan is also available for use in 12- to 18-year olds. If you go back to your doctor now, I am sure that she will be happy to discuss this with you.

I went to see my doctor for some help with my migraines and he suggested I try a triptan. I read the list of side effects and I am concerned about taking it.

Triptans are a very effective way of treating migraine. The side effects listed may possibly occur but do not affect all of the people all of the time. Some people get no side effects at all, and others feel that the side effects they get are worth the benefit of an effectively treated attack.

The reason triptans cause this range of side effects is that they attach themselves to nerve receptors in all parts of the body, although they attach themselves best to the receptors within the brain. Different triptans can cause different side effects in different people, although studies suggest that some are less likely to cause side effects than others.

If you are concerned, go back and have a chat with your doctor about it. It would be a shame to miss out on something that may because you no problems whatsoever while getting rid of your migraine well.

The triptan I am taking gets rid of the headache of my migraine but makes me feel quite unwell. Is there anything I can do?

Any triptan can cause side effects in some of the people some of the time. But there are some that have been found to be less likely than others to cause problems. It is, however, impossible to predict how any one person is going to react. Almotriptan and naratriptan are associated with the least side effects, so, if you have not tried either of these, they might be worth a go.

You could also ask yourself whether, with the headache gone, you are perhaps just more aware of the other symptoms, rather than your symptoms being a side effect of the medication. I would encourage you to reflect on these options before giving up on the triptan.

What sorts of side effects should I expect to get when taking my triptan?

The side effects that you get are because the triptans target receptors on all blood vessels but have their maximum effect on the blood vessels in the brain. You may not get any side effects at all, but if you do experience problems the sorts of symptoms you might expect include:

• Tingling or other sensory changes

• A feeling of heat

• A feeling of heaviness, pressure, or tightness affecting any part of the body, most notably the throat or chest

• Flushing

• Dizziness

• A feeling of weakness or fatigue

• Nausea and vomiting

• Dry mouth

• Indigestion or dyspepsia

If you do experience any of these side effects, have a chat with your doctor. Each triptan is different and how you react to them will vary, so it is worth trying a different one to see if it suits you better, or try a lower dose if there is one.

I have just started using a triptan to treat my migraine. Are there any tablets or drugs that I should not take whilst using my triptan? It works really well and I just want to be prepared.

There are a variety of drug interactions that you should be aware of, and some of them are more likely to be an issue than others. Your doctor is likely to be made aware of these when issuing the prescription, especially when using a computer as it routinely ‘red flags’ potential interactions. Your local pharmacist is also likely to be aware of possible drug interactions so if you have any concerns just check with them.

Drug interactions with triptans*

Triptan – Drug interactions and precautions

Almotriptan – Ergot or methysergide: avoid for 24 hours after use Avoid St John’s wort at the same time

Eletriptan Avoid clarithromycin and erythromycin (antibiotics) – Ergot or methysergide: avoid for 24 hours after use Itraconazole, ketoconazole (anti-fungal drugs): avoid concomitant use – risk of toxicity Indinavir, nelfinavir, ritonavir (anti-viral drugs): avoid concomitant use – risk of toxicity Avoid St John’s wort at the same time.

Frovatriptan – Fluvoxamine: may inhibit metabolism SSRIs: possible increased serotonergic effect Ergot or methysergide: avoid for 24 hours after use Avoid St John’s wort at the same time

I find that there are times when my triptan works better than others. Why is this?

Answering that question is not easy. Timing is the first thing I tend to check. If you take your triptan within one hour of the headache starting, it is likely to be more effective than if you take it later. Remember, too, that triptans are not designed to work if they are taken too early – during the warning or aura phase.

Drug interactions with triptans* (cont’d)

Naratriptan – No significant drug interactions listed

Rizatriptan – MAOIs: avoid for 2 weeks after use of triptan Moclobemide (antidepressant): avoid for 2 weeks after use – risk of CNS toxicity Propranolol: use 5 mg dose Ergot or methysergide: avoid for 24 hours after use Avoid St John’s wort at the same time

Sumatriptan – Increased risk of CNS toxicity with citalopram, escitalopram, fluoxetine, fluvoxamine (antidepressants) Sertraline: avoid concomitant use MAOIs: avoid for 2 weeks after use of triptan Moclobemide (antidepressant): avoid for 2 weeks after use – risk of CNS toxicity Ergot or methysergide: avoid for 24 hours after use Avoid St John’s worth at the same time

Zolmitriptan – Quinolones (antibiotics): reduce dose of triptan MAOIs: increased risk of CNS toxicity Moclobemide (antidepressant): reduce dose of zolmitriptan Fluvoxamine (SSRI): reduce dose of zolmitriptan Ergot or methysergide: avoid for 24 hours after use Cimetidine: reduce dose of zolmitriptan Avoid St John’s worth at the same time

Triptans do not work for every attack, and they do not always work as well for some attacks as others. The reasons for this are not clear but probably reflect differences in the absorption of the drug during the early phases of the attack and also the variation that occurs from attack to attack in the normal course of events.

I went to see a specialist and he says I should take ibuprofen and my triptan together. I don’t like taking too many tablets, though, so is this all right?

If your triptan on its own isn’t enough to completely stop your migraine, taking ibuprofen at the same time is a good idea. The two may well work better together than one or the other on its own. The idea behind using both is to reduce the total number of headache days you experience.

I always know when my attack is going to start but my triptan does not seem to work. Why is that?

You may well know exactly when your attack is going to start, but if you take the triptan before the headache starts it is not going to work. You need to wait until the headache itself begins to get the best result from your triptan. Ideally, it should be taken within one hour of the headache starting. Some of my attacks start with an aura and others do not.

My doctor told me to take my triptan as soon as my attack starts. I have found that this only works in the attacks that do not have an aura. I think I should wait until the headache starts. Am I right to delay treatment in that way?

Yes, you are. Triptans work on very specific receptors and have been designed to work in the headache phase. Your GP is right, provided your attack starts with a headache and not an aura.

My doctor has suggested that I try a nasal spray instead of my usual tablets. Why?

The most likely reason is to offer you a treatment that will work more quickly than the one you are currently using. A significant number of people have found that nasal sprays start to work within 20 to 30 minutes of being taken, so a spray is likely to work more quickly than your tablet.

My triptan always gets rid of my migraine headache within two to three hours but I find that it will usually come back later that day or sometimes the next day. Is there anything I can do to stop this?

Headache recurrence happens with a lot of migraine attacks. It occurs in part as a result of how the triptan works or the nature of the migraine attack itself; a migraine attack can last up to 72 hours. There are a variety of things that you might want to try. First, check that you took your triptan as early as you could at the start of the headache. Secondly, if you get an aura or other warning symptoms, try something such as ibuprofen as soon as those symptoms begin. Another option is to take ibuprofen regularly through the rest of the day.

Is it better to take sumatriptan 50 mg or sumatriptan 100 mg?

When sumatriptan was initially developed it was launched as a 100 mg dose. This dose is very effective but can cause side effects (discussed a little earlier) and it has since been found that 50 mg can work just as well in some people. In the United States they use a 25 mg dose as well. The best dose is the one that takes away your headache quickly, causes few or no side effects, and does not allow the headache to come back within the next 24 to 48 hours. Only you can decide which one is better – not always an easy choice. You need to be confident that what you take will work well for you, relieving all of the symptoms of your attack and not allowing the symptoms to recur.

My specialist suggested that a nasal spray would be better for my migraine but I hate the taste that I get down the back of my throat. It seems to work really well, though, so is there anything I can do to help gets rid of the taste?

If you lean forward while you take the nasal spray rather than sit upright, it is less likely to trickle down the back of your throat. You don’t say which nasal spray you are taking. There are two different ones, so you could try the other one. If you don’t get the taste problem but it doesn’t work as well, then you’ll have to decide what you want to do. Do you accept the taste with the one that works better or use the one that isn’t quite as good but doesn’t cause any problems?

Only you can decide that one. Have you tried a drink or sucking on a sweet afterwards? I know if you are feeling nauseated that might not be a good idea but it could be worth giving it a go.

I have tried three or four different triptans but none of them seems to work. Why is that?

It depends on what you mean by ‘not working’. If you mean it only eases the headache rather than taking it away completely, that may well be par for the course for the triptans you have tried. If ‘not working’ means no effect on your symptoms at all, again that simply reflects your response to those particular drugs. Are you perhaps taking it too early or too late?

Every single person has a different response to each of the seven triptans that are currently available. Each triptan works best if taken early in the headache phase or if taken with a painkiller/anti-inflammatory such as ibuprofen. The only way to find out which triptan suits you best is to try each of them for three consecutive attacks and then decide. You will need to enlist the help of your doctor in prescribing them, but trying each triptan in turn is the only way you will find out.

My triptan gets rid of the headache but I still feel nauseated and very, very tired. Should I try something different?

Headache is only part of a migraine attack. The other symptoms are nausea, vomiting, and sensitivity to light and sound as well as poor concentration and tiredness. A triptan can treat all the symptoms of a migraine attack but there are times when the best it can do

is relieve the headache. The nausea can be treated by taking something such as domperidone or metoclopramide. These can be taken either before or at the same time as your triptan. The tiredness is slightly more problematic. Having a lie down in the first few hours of the attack may be the only option.

Even after the pain is gone, it takes another day or so for me to get better. Is this normal?

Yes, it is. It’s called the recovery phase and can last several hours or the rest of the day. Some people feel tired, washed out and lethargic whilst others actually feel full of energy and the need to do things.