Use in Adults
Triptan Tablets
THIS GUIDE PROVIDES A PARTIAL LISTING OF PRESCRIBING INFORMATION FOR THIS MEDICATION. FOR A FULL LISTING OF PRESCRIBING INFORMATION PLEASE REFER TO THE PACKAGE INSERT. CLICK ON THE BRAND NAME® TO VIEW THE LINK TO THE PACKAGE INSERT.
almotriptan (Axert®) Click Here to Expand
Brands:
- Axert® (almotriptan malate) For more complete prescribing information click here for PACKAGE INSERT
- 6.75 and 12.5 mg tablets
- 12.5 mg is the preferred initial dosage
- Might consider 6.75 mg tablets in patients who are triptan intolerant
- 12.5 mg by mouth at onset of migraine, may repeat in 2 hours if not pain free or inadequate pain relief
- 25 mg
- Nausea, dizziness, sleepiness, fatigue, tightness in the throat, chest pain, feeling of pins and needles in hands or feet.
- Almotriptan is considered one of the fast-acting oral triptans that also includes eletriptan, rizatriptan, sumatriptan and zolmitriptan.
- Commonly used as a first line acute therapy for migraine.
- Almotriptan has a lower incidence of the “triptan side effects” (eg. paresthesias, neck tightness, chest pain/tightness, dizziness, somnolence) than other triptans such as sumatriptan, rizatriptan and zolmitriptan. Therefore, one might consider prescribing triptan in those that are intolerant to “triptan side effects” from the other triptans.
- Almotriptan should not be used in those with known cardiovascular disease (CAD, stroke, Prinzmetal’s angina, peripheral vascular disease, mesenteric ischemia), hemiplegic migraine and basilar type migraine. It should be used with caution in those with two more cardiovascular risk factors. Some clinicians recommend cardiac evaluation to exclude unrecognized cardiovascular disease prior to use of sumatriptan or other triptans in patients who have two or more cardiovascular risk factors.
- Limit use to 10 or fewer days per month to prevent medication overuse headache.
- Main advantages are good efficacy and a long safety record for use.
- Main disadvantages are a higher incidence of side effects and potential need to screen for cardiovascular or other vascular risks prior to use of the triptans.
- Many insurance plans require that those with migraine “try and fail” 1-2 triptans prior to using other newer acute medications (e.g., gepants, ditans and some older agents such as ergots).
- Do not use in the setting of coronary artery disease, unstable angina, hx of stroke, basilar type or hemiplegic migraine, uncontrolled hypertension, vasculitides, including ischemic bowel disease.
- Limit use to 10 or fewer days per month to prevent medication overuse headache.
- Cerebrovascular syndromes (e.g., strokes of any type or transient ischemic attacks)
- Concomitant use of any ergotamine-containing or ergot-type medication (e.g., dihydroergotamine or methysergide) within 24 hours of each other
- Concomitant use of a different triptan or ergot within 24 hours
- Hemiplegic or basilar type migraine
- Hypersensitivity to almotriptan or any of its components
- Ischemic heart disease or coronary artery vasospasm, including Prinzmetal’s variant angina or any significant or underlying cardiovascular disease
- Ischemic cardiac syndromes, history, symptoms, or signs (e.g., angina pectoris of any type, myocardial infarction of any form, silent myocardial ischemia)
- Peripheral vascular disease (e.g., ischemic bowel disease)
- Uncontrolled hypertension; may increase blood pressure
- Click Axert® and navigate to #8 Use in Special Populations (8.1 & 8.2)
- Do not use within 24 hours of another triptan or ergotamine
- Pharmacists frequently report a drug interaction between triptans and anti-depressants because of the risk of serotonin syndrome. However, this is felt to be a theoretical risk. Sufficient evidence to support the contention that combined use of triptans and serotonergic anti-depressants is unsafe has not been established. This is reflected in a position statement from the American Headache Society (Evans R. Headache 2010; 50: 1089-99) Therefore, headache physicians commonly co-administer antidepressants and triptans in the same patient.
- Dose reduction needed with strong CYP3A4 inhibitor including protease inhibitors, clarithromycin, erythromycin, and antifungals.
- May repeat in 2 hours.
- Not contraindicated with MAO inhibitors, but some is metabolized by MAOs.
- Dose reduction needed with strong CYP3A4 inhibitor.
Eletriptan (Relpax®) click here to expand
Brands:
- Relpax® (eletriptan hydrobromide) For more complete prescribing information click here for PACKAGE INSERT
- 20 and 40 mg tablets
- 40 mg is the preferred initial dosage
- 20 mg could be used in patients with medication intolerances
- 40 mg by mouth at onset of migraine, may repeat dose in two hours if not pain free or with inadequate pain relief
- 80 mg per day
- Nausea, dizziness, sleepiness, fatigue, tightness in the throat, chest pain, feeling of pins and needles in hands or feet.
- Eletriptan is considered one of the fast-acting oral triptans that also includes almotriptan, rizatriptan, sumatriptan and zolmitriptan.
- Commonly used as a first line acute therapy for migraine.
- Triptans have a higher incidence of side effects than many NSAIDS and gepants. Side effects include paresthesias, neck tightness, chest pain/discomfort, dizziness and somnolence, which have been termed “triptan side effects”. Patients need to be warned of these side effects prior to their initial use. If not, some patients may delay use of triptans because of fear of these side effects.
- Eletriptan should not be used in those with known cardiovascular disease (CAD, stroke, Prinzmetal’s angina, peripheral vascular disease, mesenteric ischemia), hemiplegic migraine and basilar type migraine. It should be used with caution in those with two more cardiovascular risk factors. Some clinicians recommend cardiac evaluation to exclude unrecognized cardiovascular disease prior to use of sumatriptan or other triptans in patients who have two or more cardiovascular risk factors.
- Main advantages are good efficacy and a long safety record for use.
- Main disadvantages are a higher incidence of side effects and the potential need to screen those with migraine for cardiovascular or other vascular risk prior to use of the triptans.
- Many insurance plans require that those with migraine “try and fail” 1-2 triptans prior to using other newer acute medications (e.g., gepants, ditans and some older agents such as ergots).
- Do not use in the setting of coronary artery disease, unstable angina, hx of stroke, basilar-type or hemiplegic migraine, uncontrolled hypertension, vasculitides, including ischemic bowel disease.
- Limit use to 10 or fewer days per month to prevent medication overuse headache.
- Ischemic coronary artery disease (angina pectoris, history of myocardial infarction or documented silent ischemia) or coronary artery spasm, including Prinzmetal’s angina
- Wolff-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders
- History of stroke, TIA, or history or current evidence of hemiplegic or basilar type migraine
- Peripheral vascular disease
- Ischemic bowel disease
- Uncontrolled hypertension
- Recent use (i.e., within 24 hours) of a different triptan, ergotamine containing medication, or ergot-type medication (e.g., dihydroergotamine or methysergide)
- Hypersensitivity to eletriptan hydrobromide (i.e., angioedema or anaphylaxis)
- Recent use (i.e., within at least 72 hours) of treatment with the following potent CYP3A4 inhibitors: ketoconazole, itraconazole, nefazodone, troleandomycin, clarithromycin, ritonavir, or nelfinavir
- Click Relpax® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- Eletriptan has a drug interaction with potent CYP3A4 inhibitors such as protease inhibitors, clarithomyin, erythromycin and antifungals. Its administration should be avoided in these instances.
- Do not use within 24 hours of another triptan or ergotamine
- Pharmacists frequently report a drug interaction between triptans and anti-depressants because of the risk of serotonin syndrome. However, this is felt to be a theoretical risk. Sufficient evidence to support the contention that combined use of triptans and serotonergic anti-depressants is unsafe has not been established. This is reflected in a position statement from the American Headache Society (Evans R. Headache 2010; 50: 1089-99) Therefore, headache physicians commonly co-administer antidepressants and triptans in the same patient.
- Meta-analysis has suggested greater efficacy and improved tolerability with eletriptan compared with other triptans.
frovatriptan (Frova®) Click here to Expand
Brands:
- Frova® (frovatriptan succinate) For more complete prescribing information click here for PACKAGE INSERT
- 2.5 and 5 mg tablets
- 2.5 mg or 5 mg
- 2.5 mg or 5 mg by mouth at onset of migraine
- May repeat dosage 2 hours after initial dosage if inadequate treatment response
- 10 mg
- Nausea, dizziness, sleepiness, fatigue, tightness in the throat, chest pain, feeling of pins and needles in hands or feet.
- Frovatriptan has a lower incidence of the “triptan side effects” (eg. paresthesias, neck tightness, chest pain/tightness, dizziness, somnolence) than other triptans such as sumatriptan, rizatriptan and zolmitriptan. Therefore, one might consider prescribing triptan in those who are intolerant of “triptan side effects” from the other triptans.
- May be used to treat headaches that frequently recur 2-24 hours after the initial dosage of an acute medication (e.g., menstrual migraine) since the medication has a long elimination half-life.
- Frovatriptan should not be used in those with known cardiovascular disease (CAD, stroke, Prinzmetal’s angina, peripheral vascular disease, mesenteric ischemia), hemiplegic migraine and basilar type migraine. It should be used with caution in those with two more cardiovascular risk factors. Some clinicians recommend cardiac evaluation to exclude unrecognized cardiovascular disease prior to use of sumatriptan or other triptans in patients who have two or more cardiovascular risk factors.
- Main advantages are good efficacy and a long safety record for use.
- Main disadvantage is the potential need to screen for cardiovascular or other vascular risks prior to use of the triptans.
- Many insurance plans require that those with migraine “try and fail” 1-2 triptans prior to using other newer acute medications e.g., gepants, ditans and some older agents such as ergots.
- Do not use in the setting of coronary artery disease, unstable angina, hx of stroke, basilar-type or hemiplegic migraine, uncontrolled hypertension, vasculitides, including ischemic bowel disease.
- Limit use to 10 or fewer days per month to prevent medication overuse headache.
- Coronary artery vasospasm, including Prinzmetal’s angina
- Ergotamine-containing or ergot-type drugs, recent use (i.e., within 24 hours)
- Different triptan or ergot, recent use (i.e., within 24 hours)
- Hemiplegic or basilar-type migraine, history
- Hypersensitivity to frovatriptan succinate (angioedema and anaphylaxis seen)
- Hypertension, uncontrolled
- Ischemic bowel disease
- Ischemic coronary artery disease (e.g., confirmed silent ischemia, angina pectoris, history of myocardial infarction)
- Peripheral vascular disease
- Stroke or TIA, history
- Wolf-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders
- Click Frova® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- Do not use within 24 hours of another triptan or ergotamine
- Pharmacists frequently report a drug interaction between triptans and anti-depressants because of the risk of serotonin syndrome. However, this is felt to be a theoretical risk. Sufficient evidence to support the contention that combined use of triptans and serotonergic anti-depressants is unsafe has not been established. This is reflected in a position statement from the American Headache Society (Evans R. Headache 2010; 50: 1089-99) Therefore, headache physicians commonly co-administer antidepressants and triptans in the same patient.
- May repeat in 2 hours.
- Frovatriptan has a slower onset of action compared with faster acting triptans (eg. almotriptan, eletriptan, rizatriptan, sumatriptan, zolmitriptan). Its onset of action is 3-4 hours after the initial dosage as compared to 1-2 hours with the faster acting triptans.
- Frovatriptan has a long elimination half- life and in clinical trials was shown to have a lower risk of recurrence of migraine 2-24 hours after the initial dosage than the faster acting triptans. Frovatriptan may be a good choice in long duration attacks or in patients whose attacks typically recur despite effective acute treatment, such as menstrual migraine attacks.
Naratriptan (Amerge®) Click Here to Expand
Brands:
- Amerge® (naratriptan hydrochloride) For more complete prescribing information click here for PACKAGE INSERT
- 1 mg and 2.5 mg
- 2.5 mg is the preferred initial dosage
- 1 mg can be used in those with triptan intolerance
- 2.5 mg by mouth at onset of migraine; can readminister 4 hours after initial dosage if migraine not adequately relieved by initial dosage or if the headache recurs. May be used twice daily;
- 5 mg per 24-hour period
- Nausea, dizziness, sleepiness, fatigue, tightness in the throat, chest pain, feeling of pins and needles in hands or feet.
- Naratriptan has a lower incidence of the “triptan side effects” (e.g., paresthesias, neck tightness, chest pain/tightness, dizziness, somnolence) than other triptans, such as, sumatriptan, rizatriptan and zolmitriptan. Therefore, one might consider prescribing naratriptan in those patients who are intolerant of the “triptan side effects” experienced with the other triptans.
- Naratriptan has a long elimination half- life and has been shown to have a lower risk of recurrence of migraine 2-24 hours after the initial dosage than the faster acting triptans (e.g., almotriptan, eletriptan, rizatriptan, sumatriptan, zolmitriptan). Therefore, it might be a good choice in patients whose migraine attacks tend to recur or in those patient who have long duration attacks, common in menstrual migraine attacks.
- Naratriptan should not be used in those with known cardiovascular disease (CAD, stroke, Prinzmetal’s angina, peripheral vascular disease, mesenteric ischemia), hemiplegic migraine and basilar type migraine. It should be used with caution in those with two more cardiovascular risk factors. Some clinicians recommend cardiac evaluation to exclude unrecognized cardiovascular disease prior to use of sumatriptan or other triptans in patients who have two or more cardiovascular risk factors.
- Main advantages are good efficacy and a long safety record for use.
- Main disadvantage is the potential need to screen those with cardiovascular or other vascular risks prior to use of the triptans.
- Many insurance plans require that those with migraine “try and fail” 1-2 triptans prior to using other newer acute medications (e.g., gepants, ditans and some older agents such as ergots).
- Do not use in the setting of coronary artery disease, unstable angina, hx of stroke, basilar type or hemiplegic migraine, uncontrolled hypertension, vasculitides, including ischemic bowel disease.
- Limit use to 10 or fewer days per month to prevent medication overuse headache.
- Concomitant use of ergotamine-containing or ergot-type agent (e.g., dihydroergotamine or methysergide) within 24 hours
- Concomitant use with different triptan or ergot within 24 hours
- Coronary artery vasospasm (including Prinzmetal’s angina)
- History of hemiplegic or basilar type migraine
- History of stroke or TIA
- Hypersensitivity to naratriptan; angioedema and anaphylaxis have been reported [2]
- Ischemic bowel disease
- Ischemic coronary artery disease (e.g., angina pectoris, history of myocardial infarction, confirmed silent ischemia)
- Peripheral vascular disease
- Severe hepatic impairment (Child-Pugh Grade C)
- Severe renal impairment (CrCl less than 15 mL/min)
- Uncontrolled hypertension
- Wolff-Parkinson-White syndrome or arrhythmias attributed to cardiac accessory conduction pathway disorders
- Click Amerge® and navigate to #8 Use in Specific Populations (8.1 & 8.2
- Do not use within 24 hours of another triptan or ergotamine
- Pharmacists frequently report a drug interaction between triptans and anti-depressants because of the risk of serotonin syndrome. However, this is felt to be a theoretical risk. Sufficient evidence to support the contention that combined use of triptans and serotonergic anti-depressants is unsafe has not been established. This is reflected in a position statement from the American Headache Society (Evans R. Headache 2010; 50: 1089-99) Therefore, headache physicians commonly co-administer antidepressants and triptans in the same patient.
- Oral formulations of triptans are some of the most commonly prescribed acute medications for migraine because tablets are preferred by patients. However, nasal and injectable formulations of triptans have a faster onset of action.
- May repeat in 4 hours. Has demonstrated effectiveness in both acute treatment of menstrual migraine and in short term prevention of menstrual migraine.
- Naratriptan has a slower onset of action compared with faster acting triptans (e.g,. almotriptan, eletriptan, rizatriptan, sumatriptan, zolmitriptan). Its onset of action is 3-4 hours after the initial dosage as compared to 1-2 hours with the faster acting triptans in clinical trials, although many patients report faster onset of action in clinical practice.
rizatriptan (Maxalt®) click here to Expand
Brands:
- Maxalt® (rizatriptan benzoate) For more complete prescribing information click here for PACKAGE INSERT
- 5 mg and 10 mg dosages
- Can be administered as a tablet or MLT formulation
- The MLT formulation melts on the tongue and can be swallowed without water
- 10 mg is the preferred initial dosage
- 5 mg can be used in those with medication intolerance or in those receiving propranolol as its coadministration can raise levels of rizatriptan
- 10 mg by mouth at onset of migraine attack, may repeat in 2 hours if not pain free or adequate pain relief
- 30 mg per 24 hour period
- Nausea, dizziness, sleepiness, fatigue, tightness in the throat, chest pain, feeling of pins and needles in hands or feet.
- Rizatriptan is considered one of the fast-acting oral triptans that also includes almotriptan, eletriptan, sumatriptan, and zolmitriptan.
- Rizatriptan, both the regular tablet and MLT formulation are commonly used as a first line acute therapy for migraine.
- Triptans have a higher incidence of side effects than many NSAIDS and gepants. Side effects include paresthesias, neck tightness, chest pain/discomfort, dizziness and somnolence, which have been termed “triptan side effects”. Patients need to be warned of these side effects prior to their initial use. If not, some patients may delay use of triptans because of fear of these side effects.
- Rizatriptan should not be used in those with known cardiovascular disease (CAD, stroke, Prinzmetal’s angina, peripheral vascular disease, mesenteric ischemia), hemiplegic migraine and basilar type migraine. It should be used with caution in those with two more cardiovascular risk factors. Some clinicians recommend cardiac evaluation to exclude unrecognized cardiovascular disease prior to use of sumatriptan or other triptans in patients who have two or more cardiovascular risk factors.
- Main advantages are good efficacy, a long safety record for use and multiple formulations from which to choose (e.g., tablets, MLT).
- Main disadvantages are a higher incidence of side effects and the potential need to screen those with cardiovascular or other vascular risks prior to use of the triptans.
- Many insurance plans require that those with migraine “try and fail” 1-2 triptans prior to using other newer acute medications (e.g., gepants, ditans and some older agents such as ergots).
- Do not use in the setting of coronary artery disease, unstable angina, hx of stroke, basilar-type or hemiplegic migraine, uncontrolled hypertension, vasculitides, including ischemic bowel disease.
- Limit use to 10 or fewer days per month to prevent medication overuse headache.
- Concomitant use of MAO-A inhibitors or nonselective MAOIs or use within 2 weeks of discontinuation of MAOI therapy
- Concomitant use with another triptan within 24 hours
- Coronary artery vasospasm, including Prinzmetal’s angina
- Hemiplegic or basilar-type migraine
- Hypersensitivity to rizatriptan or any other components of the product
- Hypertension, uncontrolled
- Ischemic bowel disease
- Ischemic coronary artery disease (i.e., angina pectoris, history of myocardial infarction, documented silent ischemia) or other significant underlying cardiovascular disease
- Peripheral vascular disease
- Recent use (within 24 hours) of ergotamine-containing or ergot-type agent, such as dihydroergotamine or methysergide
- Recent use of different triptan or ergot within 24 hours
- Stroke or TIA, history
- Click Maxalt® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- Propranolol can increase serum levels of rizatriptan. Therefore, the 5 mg dosage of rizatriptan is used if patients are taking propranolol.
- Do not use within 24 hours of another triptan or ergotamine
- Pharmacists frequently report a drug interaction between triptans and anti-depressants because of the risk of serotonin syndrome. However, this is felt to be a theoretical risk. Sufficient evidence to support the contention that combined use of triptans and serotonergic anti-depressants is unsafe has not been established. This is reflected in a position statement from the American Headache Society (Evans R. Headache 2010; 50: 1089-99) Therefore, headache physicians commonly co-administer antidepressants and triptans in the same patient.
- May repeat dosage after 2 hours.
- Use a 5 mg tablet if also taking propranolol (max total daily dose: 15 mg).
- If not on propranolol, maximum daily dosage is 30 mg
- Rizatriptan has a both tablet and MLT formulations. The MLT formulation is placed on the tongue and melts in the mouth then medication is swallowed and absorbed in the gastrointestinal tract. MLT tablets do not require water. The tablet and MLT formulations have similar onsets of action and efficacy.
sumatriptan (Imitrex®) Click Here to Expand
Brands: Available Dosages:
- 25, 50 and 100 mgs
- 100 mg at onset of migraine attack
- If patient has unpleasant side effects then you may consider a 25 or 50 mg dosage for future attacks
- 100 mg by mouth at onset of migraine attack, may repeat in 2 hours if not pain free
- If headache pain improves initially but then recurs or worsens within 2 to 24 hours after the initial dose then you can take a second dosage
- 200 mg
- Tightness in throat and chest, dizziness, or sedation/fatigue, tingling in the hands and feet
- Oral formulations of triptans are the most commonly prescribed acute medications for migraine as tablets are usually preferred by patients. However, nasal and injectable formulations of triptans are known to have a faster onset of action.
- Oral sumatriptan is commonly used as a first line acute therapy for migraine.
- Sumatriptan is considered one of the fast-acting oral triptans, a group that also includes almotriptan, eletriptan, rizatriptan, and zolmitriptan.
- Triptans have a higher incidence of side effects than many NSAIDS and gepants. Side effects can include paresthesias, neck tightness, chest pain/discomfort, dizziness and somnolence, which have been termed “triptan side effects”. Patients should be warned of these side effects prior to their initial use. If not, some patients may delay use of triptans because of they fear these side effects.
- Sumatriptan should not be used in those with known cardiovascular disease (CAD, stroke, Prinzmetal’s angina, peripheral vascular disease, mesenteric ischemia), hemiplegic migraine and basilar type migraine.
- Sumatriptan should be used with caution in those with two more cardiovascular risk factors. Some clinicians recommend cardiac evaluation to exclude unrecognized cardiovascular disease prior to use of sumatriptan or other triptans in patients who have two or more cardiovascular risk factors.
- Main advantages are good efficacy, a long safety record for use and multiple formulations from which to choose (e.g., tablets, nasal sprays, injectables).
- Main disadvantages are a higher incidence of side effects and the potential need to screen those with migraine for cardiovascular or other vascular risk prior to use of the triptans.
- Many insurance plans require that those with migraine “try and fail” 1-2 triptans prior to using other newer acute medications (e.g., gepants, ditans and some older agents such as ergots).
- Do not use in the setting of coronary artery disease, unstable angina, hx of stroke, basilar-type or hemiplegic migraine, uncontrolled hypertension, vasculitides, including ischemic bowel disease.
- Limit use to 10 or fewer days per month to prevent medication overuse headache.
- Arrhythmias associated with cardiac accessory conduction pathway disorders, including Wolff-Parkinson-White syndrome
- Concomitant administration of MAO-A inhibitors or use within 2 weeks of discontinuation of MAO-A inhibitor therapy
- Concomitant use of ergotamine-containing or ergot-type medication (e.g., dihydroergotamine, methysergide) within 24 hours
- Concomitant use with a triptan or ergot within 24 hours
- Coronary artery vasospasm, including Prinzmetal’s angina, or other significant underlying cardiovascular disease
- History of hemiplegic or basilar-type migraine
- History of stroke or transient ischemic attack
- Hypersensitivity to sumatriptan or any of its components
- Ischemic bowel disease
- Ischemic coronary artery disease (angina pectoris, history of myocardial infarction, or documented silent ischemia)
- Peripheral vascular disease
- Severe hepatic impairment
- Uncontrolled hypertension
- Click Imitrex® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- Do not use within 24 hours of another triptan or ergotamine
- Pharmacists frequently report a drug interaction between triptans and serotonergic anti-depressants because of the risk of serotonin syndrome. However, this is felt to be a theoretical risk. Sufficient evidence to support the contention that combined use of triptans and serotonergic anti-depressants is unsafe has not been established. This is reflected in a position statement from the American Headache Society. (Evans R. Headache 2010; 50: 1089-99) Therefore, headache specialists commonly co-administer antidepressants and triptans in the same patient.
Zolmitriptan (Zomig®) Click here to expand
Brands:
Initial Dose:
- Zomig ZMT® (zolmitriptan) For more complete prescribing information click here for PACKAGE INSERT
- 2.5 and 5 mg
Initial Dose:
- 5 mg is the preferred initial dosage
- If patient is triptan intolerant, offer the 2.5 mg dosage
- 2.5 mg or 5 mg by mouth at onset of migraine, may repeat dosage in 2 hours after the initial dosage if not pain free or if inadequate pain relief
- 10 mg
- Nausea, dizziness, sleepiness, fatigue, tightness in the throat, chest pain, feeling of pins and needles in hands or feet.
- Zolmitriptan is considered one of the fast-acting oral triptans that also includes almotriptan, eletriptan, rizatriptan and sumatriptan.
- Zolmitriptan is commonly used as a first line acute therapy for migraine.
- Triptans have a higher incidence of side effects than many NSAIDS and gepants. Side effects include paresthesias, neck tightness, chest pain/discomfort, dizziness and somnolence, which have been termed “triptan side effects”. Patients need to be warned of these side effects prior to their initial use. If not, some patients may delay use of triptans because of fear of these side effects.
- Zolmitriptan should not be used in those with known cardiovascular disease (CAD, stroke, Prinzmetal’s angina, peripheral vascular disease, mesenteric ischemia), hemiplegic migraine and basilar type migraine. It should be used with caution in those with two more cardiovascular risk factors. Some clinicians recommend cardiac evaluation to exclude unrecognized cardiovascular disease prior to use of sumatriptan or other triptans in patients who have two or more cardiovascular risk factors.
- Main advantages are good efficacy and a long safety record for use.
- Main disadvantages are a higher incidence of side effects and the need to screen for cardiovascular or other vascular risks prior to use of the triptans.
- Many insurance plans require that those with migraine “try and fail” 1-2 triptans prior to using other newer acute medications (e.g., gepants, ditans and some older agents such as ergots).
- Do not use in the setting of coronary artery disease, unstable angina, hx of stroke, basilar type or hemiplegic migraine, uncontrolled hypertension, vasculitides, including ischemic bowel disease.
- Limit use to 10 or fewer days per month to prevent medication overuse headache.
- Ischemic coronary artery disease (e.g., angina pectoris, history of myocardial infarction, or documented silent ischemia)
- Significant cardiovascular disease
- Coronary artery vasospasm, including Prinzmetal’s angina
- Wolff-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders
- History of stroke or transient ischemic attack
- History of hemiplegic or basilar migraine
- Peripheral vascular disease
- Ischemic bowel disease
- Uncontrolled hypertension
- Recent use (within 24 hours) of a different triptan, ergotamine-containing, or ergot-type medications (e.g., dihydroergotamine or methysergide)
- Concomitant or recent (within 2 weeks) MAO-A inhibitor use
- Known hypersensitivity to zolmitriptan
- Click Zomig ZMT® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- Do not use within 24 hours of another triptan or ergotamine
- Pharmacists frequently report a drug interaction between triptans and anti-depressants because of the risk of serotonin syndrome. However, this is felt to be a theoretical risk. Sufficient evidence to support the contention that combined use of triptans and serotonergic anti-depressants is unsafe has not been established. This is reflected in a position statement from the American Headache Society (Evans R. Headache 2010; 50: 1089-99) Therefore, headache physicians commonly co-administer antidepressants and triptans in the same patient.
- Zolmitriptan can be administered as a tablet or orally disintegrating tablet (ODT). There is no difference in the onset of action or efficacy between these two formulations.