Triptans

What are migraine and cluster headaches?

Migraine is a condition that causes episodes ('attacks') of headaches, and often other symptoms such as feeling sick or vomiting. Between migraine attacks, the symptoms go completely. Cluster headaches consist of attacks of severe one-sided pain in the head.

This leaflet is about triptans that are used to treat migraine attacks and cluster headaches. It is assumed that you have some general knowledge about migraine or cluster headaches, but would like to know more about triptans. (See separate leaflets called 'Migraine' and 'Headache - Cluster Headache' for more details about these conditions.)

What are triptans?

Triptans are a class (group) of drugs that are used to ease the symptoms of a migraine attack or cluster headache. They include: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, and come in various different brand names. They are also known as 5HT1 agonists. They come as tablet (both to be swallowed and in dispersible form), injection and nasal spray preparations.

How do triptans work?

The cause of migraine attacks is not clear. A theory that used to be popular was that blood vessels in parts of the brain go into spasm (become narrower) which accounted for the aura that sometimes occurs. The blood vessels were then thought to dilate (open wide) soon after, which accounted for the headache. However, this theory is not the whole story. It is now thought that some chemicals in the brain increase in activity and parts of the brain may then send out confusing signals which cause the symptoms. The exact changes in brain chemicals is not known. It is also not clear why people with migraine should develop these changes. However, something may 'trigger' a change in activity of some brain chemicals to set off a migraine attack. See separate leaflet called 'Migraine - Triggers and Diary' which gives details of possible migraine triggers.

The cause of cluster headaches is even less clear but changes in brain chemicals probably play a part.

5-Hydroxytryptamine (5HT), also known as serotonin, is a chemical found in the brain and other parts of the body. 5HT works by attaching to specific sites ('receptors') on various cells of the body. Once bound to these receptors it creates a set of reactions within the cells. 5HT has various actions in the body, depending on the type of cell being stimulated. For example, one of the effects that it has is to cause blood vessels to narrow (constrict).

Triptans, or 5HT1 agonists, target the same receptors as 5HT. Due to their chemical make up they are able to stimulate the 5HT receptors, causing the same effects as the body’s own 5HT. For example, this means they are able to cause the constriction of dilated (widened) blood vessels which is thought to occur during a migraine. They may also have some other effect on stabilising the change in activity of some brain chemicals that occur during a migraine attack.

Triptans are meant to be used during a migraine attack, not to stop one from coming on. There is some evidence that taking a triptan too early in a migraine attack may make the treatment less effective. Therefore you should wait until you feel mild discomfort (usually, the beginning of the migraine headache) rather than taking the triptan at the aura stage or when you feel that a migraine may be 'brewing'.

Which is the best triptan?

There is no 'best buy' that suits everyone. All triptans would probably work well in most people with migraine. However, there is some evidence to suggest that some are slightly more effective than others. But also, that side-effects may vary between the different types. In other words, people may respond individually to each preparation, both in terms of its effectiveness and side-effects.

Therefore, if the first triptan does not work so well, or causes bothersome side-effects, it is worth trying a different type. In some people, finding the right triptan may mean trying a few different ones. The British Association for the Study of Headache recommends that you try a triptan for three separate migraine attacks before deciding if a change to a different one is needed.

Your doctor may also advise a change the way in which the drug is given as this can help to improve effectiveness in some cases. For example, if you usually vomit during a migraine attack then zolmitriptan nasal spray or sumatriptan given by self administered injection may be options to consider.

Can I buy triptans or are they just on prescription?

Some preparations are available to buy from pharmacies. However, they should only be taken to treat migraine that has been previously diagnosed by your doctor. Most are only available on prescription.

How do I use triptans?

You should take your triptan as you start to feel a slight headache develop and NOT before this. This is because triptans have been found to be more effective when taken in this way. Triptans are designed to work rapidly - within an hour or so.

After you have taken the first dose:

• If the triptan worked to relieve your migraine headache, but then the headache returns later, you can repeat the dose after 2–4 hours. But note: each triptan has a maximum daily dose that you should not exceed. It will be written on the packet. For example, you should not take more than 300 mg of sumatriptan in 24 hours.
• If the triptan did not work, a further dose is unlikely to work and so do not take a second dose. The exception to this is zolmitriptan (2.5 mg), where an additional dose may be tried after two hours even if the first dose did not work. See the patient leaflet that comes in the drug packet for details.

Who can and cannot take triptans?

A full list of people who should not take triptans is included with the patient leaflet that comes in the drug packet. If you are prescribed a triptan, read this to be sure you are safe to take it. In particular you should not take a triptan if you:

• Have uncontrolled hypertension.
• Have, or have a high risk of developing, cardiovascular disease (angina, heart attack, etc).
• Have coronary vasospasm such as Prinzmetal's angina (this is rare).
• Are pregnant.

Traces of triptans are passed out in breast milk, so they should be avoided during breastfeeding, or milk should be discarded for 12–24 hours (see manufacturer's information).

A reduced dose is recommended for some triptans if you have certain kidney or liver conditions - your doctor will advise.

Triptans should not be taken at the same time as migraine treatments containing ergotamine. If you stop taking a triptan you must wait before taking anything containing ergotamine. If you are taking ergotamine you must also wait before taking a triptan. This waiting period varies between 12 and 24 hours depending on the type of triptan. Speak to your doctor or pharmacist if this applies to you.

There are age restrictions on the use of triptans:

• Children younger than 12 years of age should not take triptans.
• Adolescents (12–18 years of age) may be prescribed sumatriptan nasal spray (10 mg).
• Triptans are not licensed for people aged over 65 years.

What about side-effects?

Most people who take triptans do not have any serious side-effects. However, they can cause drowsiness. If drowsiness occurs, you should not drive or perform other skilled tasks while affected.

The other most common side-effects are: nausea (feeling sick), dizziness and dry mouth.

In addition, triptans can also cause some people to experience strange sensations. These may be a tightness, tingling, flushing, and feelings of heaviness or pressure in areas such as the face and limbs, and occasionally the chest. These 'triptan sensations' in the chest can mimic angina (heart pains) and may cause alarm. Usually these sensations are not harmful. However, if you develop intense chest pain or sensations you should stop taking your medication and consult a doctor immediately or go directly to the nearest accident and emergency department (you may need to dial 999 for an ambulance).

For a full list of all the side-effects and possible interactions associated with your drug consult the leaflet that comes with your medication.

What about risks?

Triptans are usually safe if you do not have any of the medical conditions mentioned above. As explained earlier, these drugs can cause the constriction of blood vessels which is why they are not to be given to people with heart or blood vessel problems.

If you take triptans too often, you are at risk of developing medication induced headache.

What is medication induced headache?

Medication induced headache (also called medication overuse headache) is caused by taking painkillers or triptans too often for tension-type headaches or migraine attacks. It is a common cause of headaches that occur daily, or on most days. About 1 in 50 people develop this problem at some time in their life. The following is a typical case:

You may have a bad spell of tension headaches or migraine attacks, perhaps during a time of stress. You take painkillers or a triptan more often than usual. You continue doing this for a while. Therefore, your body becomes used to the painkillers or triptan. A 'rebound' or 'withdrawal' headache then develops if you do not take a painkiller or triptan within a day or so of the last dose. You think this is just another tension headache or migraine attack, and so you take a further dose of painkiller or triptan. When the effect of each dose wears off, a further withdrawal headache develops, and so on. A vicious circle develops. In time, you may have headaches on most days, or on every day, and you end up taking painkillers or a triptan every day, or on most days.

So, some people who may think they are getting frequent migraine attacks are in fact getting medication induced headache. If you use painkillers or a triptan on more than two days per week on a regular basis, you are at risk of developing medication induced headache. You should talk to your doctor if you suspect that you may have medication overuse headache. See separate leaflet called 'Headache - Medication Induced' for more details.

Further sources of help and information

Migraine Action

27 East Street, Leicester, LE1 6NB
Tel: 0116 275 8317 Web: www.migraine.org.uk

Migraine Trust

2nd Floor, 55-56 Russell Square, London, WC1B 4HP
Tel: 020 7462 6601 Web: www.migrainetrust.org