Acute treatment for migraine with a triptan

See separate advice for a child.

When a nonopioid analgesic (with or without an antiemetic) does not relieve the patient's migraine, prescribe a triptan for them to take the next time they have a migraine.

Choice of triptan depends on several factors, and is usually refined after the patient uses a triptan for the first time. If a patient has adverse effects from the first triptan, try naratriptan or eletriptan (at the lower dose of 40 mg)—sometimes these are better tolerated, but may also have a milder acute effect. If rebound headache after effective triptan treatment is a problem, naratriptan may be preferred because of its slower onset and offset. If the patient has severe early nausea, a tablet that dissolves on the tongue (eg rizatriptan) or a nonoral preparation (eg nasal or injectable sumatriptan) may be helpful.

Do not give ergotamines for 24 hours before or after a triptan.

Some patients respond better to a combination of a triptan and a nonopioid analgesic (eg aspirin, ibuprofen, naproxen).

In adults, use:

1 eletriptan 40 to 80 mg orally. If symptoms recur, wait at least 2 hours before repeating the dose (maximum dose 160 mg in 24 hours) migraine (adult) eletriptan    

OR

1 naratriptan 2.5 mg orally. If symptoms recur, wait at least 4 hours before repeating the dose (maximum dose 5 mg in 24 hours) migraine (adult) naratriptan    

OR

1 rizatriptan 10 mg orally. If symptoms recur, wait at least 2 hours before repeating the dose (maximum dose 30 mg in 24 hours) migraine (adult) rizatriptan    

OR

1 sumatriptan 20 mg intranasally. If symptoms recur, wait at least 2 hours before repeating the dose (maximum dose 40 mg in 24 hours) migraine (adult) sumatriptan    

OR

1 sumatriptan 50 to 100 mg orally. If symptoms recur, wait at least 2 hours before repeating the dose (maximum dose 300 mg in 24 hours) sumatriptan    

OR

1 zolmitriptan 2.5 mg orally. If symptoms recur, wait at least 2 hours before repeating the dose (maximum dose 10 mg in 24 hours). If 2.5 mg tolerated but not effective in previous migraine, give 5 mg at onset of next migraine migraine (adult) zolmitriptan    

OR

2 sumatriptan 6 mg subcutaneously. If symptoms recur, wait at least 1 hour before repeating the dose (maximum dose 12 mg in 24 hours). sumatriptan    

If there is no response to the first dose of triptan, do not give a second dose for the same migraine attack. The triptan can still be tried in future attacks.

Limit triptan use to less than 10 days per month. If used more often, the patient is at risk of medication overuse headache.

Patients taking a selective serotonin reuptake inhibitor (SSRI) or a serotonin and noradrenaline reuptake inhibitor (SNRI) can be prescribed a triptan. However, they must be counselled about the symptoms of serotonin toxicity (agitation, confusion, rapid heart rate, dilated pupils, muscle twitching or rigidity, sweating, diarrhoea, headache, shivering), despite its rarity.

If a patient needs treatment for acute migraine on more than 2 to 4 days per month, consider migraine prophylaxis.