Your Guide To Choosing A Triptan Drug in the Treatment of Migraines

By: Allen Douma, M.D., for AARP. Published with permission of the author. Source: AARP.org Date Posted: 2003-10-15 12:27:00-04:00

Note: The conclusions of the Oregon Health Resources Commission represent findings, at the time the report was written, for most people taking a triptan drug. However, these findings may not necessarily apply to a given individual. You should discuss these findings with your health care providers, to determine which (if any) drug is best for you.

Summary
Background
Legislative Mandate
The Review Process
Individual Differences
Drugs Reviewed
Conclusions

Summary

With the growing number of new drugs, it's more difficult for a person or their health practitioners to decide which medication best fits an individual's needs.

And, with a wide variation in the cost of drugs used to treat the same medical problem, such as migraines, it's hard to judge whether a higher priced drug is better or not.

To help overcome this challenge, legislation was passed in Oregon directed at evaluating the relative effectiveness and safety of similar medications. The resulting information can help you and your health practitioners make more informed decisions about which drugs you take and perhaps lower the cost.

As part of this process the Oregon Health Resources Commission (HRC) compared the effectiveness and side effects of "triptan" drugs in the treatment of migraines.

The HRC appointed a subcommittee, which reviewed a study done by the Oregon Health and Science University's (OHSU) Evidence-based Practice Center. The subcommittee also solicited public input from any interested party, including pharmaceutical companies.

The HRC subcommittee used all the input to make conclusions comparing how well the drugs work and the safety of these medications. All of the meetings of the subcommittee were open to the public.

In evaluating the triptan drugs, the HRC reviewed the medical studies on almotriptan (available as brand name Axert), frovatriptan (available as brand name Frova), naratriptan (available as brand name Amerge), rizatriptan (available as brand name Maxalt), sumatriptan (available as brand name Imitrex), and zolmitriptan (available as brand name Zomig). Eletriptan (available as brand name Relpax) was approved for use by the FDA after the HRC report was written and was not included in this review. Studies on eletriptan will be included in future updates of the triptan report.

Major conclusions of the subcommittee were that:

It appears that a 10 mg oral dose of rizatriptan is the most effective triptan, based on whether a person had pain relief or was pain free at 2 hours after taking a triptan plus had pain relief a 24 hours. The HRC ' s triptan subcommittee recommends that it be the initial triptan of choice for treatment of migraines after the symptoms have begun.
There is sufficient evidence to also include sumatriptan 100 mg and zolmitriptan 5 mg as effective for initial therapy for patients with migraine.
As it is well known that triptan therapy must be individualized, the triptan subcommittee strongly recommends that health plans do not require a person to change from a triptan that has already been found to be effective for that person.
Ready availability of alternate forms is necessary for patients who are unable to tolerate the oral route.
Naratriptan was found to be effective but not as effective as other triptans.
There were no published studies of almotriptan that met the criteria required by the Oregon Evidence-based Practice Center and the triptan subcommittee to be included in this review process.
Because of a lack of published studies about frovotriptan in the medical literature, it is not considered in this report.
Eletriptan was not approved for use in the United States until the end of 2002. It was not included in the list of considered medications for this round of subcommittee meetings but will be examined in the next update.
Further head-to-head comparative trials that measure the same endpoints are needed to more clearly define if there are significant differences in the safety of triptans.
There is no comparative evidence to assess differences in efficacy and safety between triptans in patients of differing race or ethnic group, age or sex.

Background

It's estimated that 18 percent of women and 6 percent of men will have migraines. Although migraine episodes can be mild, they are often severe enough to have a major impact on ability to function and quality of life as well as decreased productivity and increased absenteeism. In addition to many other lifestyle changes and medications, there are many triptans now used to treat migraines.

In review of studies, a standard definition for migraines of the International Headache Society was used. It includes the following factors:

Five or more episodes of moderate to severe headache with or without aura, each headache lasting 4 hours to 72 hours.
Headache prohibits daily activity and is aggravated by routine physical activity.
Headache has various combinations of the following characteristics:
1. One-sided, pulsing pain,
2. Nausea and/or vomiting, and
3. Hypersensitivity to light (photophobia) and sound (phonophobia).
Other types of headache are excluded, e.g. tension headache, cluster headache.
History, physical and neurological examinations do not suggest any other cause.

The exact way in which the triptan drugs work is not known. But they activate certain nerve receptors that lead to blood vessel changes and changes in pain receptors, both of which lower pain.

Triptans are taken primarily as a standard type of pill that is swallowed. However, pills that dissolve in the mouth have recently been introduced. In addition, patches and injectable forms of delivery are available and may be of particular value for those that experience nausea and vomiting as part of their migraine attacks.

When a person and their doctor decide that taking a triptan is the best choice to reduce the symptoms of migraines, they still need to decide which one to take.

But health practitioners and the general public have had little to no access to information about how one triptan compares to another. This has been true with regard to both how effective they are and how the side effects compare. This is made even more difficult because the standard recommended dose for each triptan is very different.

A major reason for this is that most drug research in humans is done primarily to show whether a particular drug is safe enough and effective enough to be approved by the Food and Drug Administration (FDA). These studies usually just compare the drug to a "sugar pill" or placebo rather than to another drug already available to treat the condition.

As consumers, we are used to having access to trustworthy information to help us make informed choices. For example, in order to choose a car many people turn to an unbiased source of information such as Consumer Reports. Until now there was nowhere to go to find this type of comparison of how different drugs treat a particular disease or medical condition.

Analyses such as those on this website are finally giving consumers and their health care providers information they can trust to help them determine which drugs are more effective and which ones have fewer side effects.

Legislative Mandate

The Oregon legislature and the Governor's office are charged with ensuring that enrollees in the state's health plan receive the most effective services at the best price. To meet this goal, in 2001 the Oregon legislature passed a bill that called for extensive review of medical studies to determine, where possible, which medications are the most effective and safest in treating specific diseases or conditions.

This review process is ongoing, and the subcommittee will use additional medical studies, as they become available, to re-evaluate, update, and modify conclusions as appropriate.

The Review Process

The Oregon Health Resources Commission appointed a special subcommittee to advise them in evaluating triptan drugs. Members included a PharmD, 4 MDs, 2 RPh's, a RN, a human resources manager, and a consumer.

In order to compare triptan drugs in the treatment of migraines as well as to compare the negative side effects, the subcommittee asked the Oregon Health and Science's University's Evidence-based Practice Center to search the medical literature to answer a set of questions the subcommittee had developed.

The subcommittee then evaluated the research data and public comments submitted during a series of meetings, all of which were open to the public.

The subcommittee paid particular attention to the effects of triptan drugs on:

pain relief at 30 minutes,
pain relief and freedom from pain at 1 hour,
pain relief and freedom from pain at 2 hours,
return to normal function at 2 hours,
productivity and health-related, quality of life improvements, and
relief of nausea, photophobia and phonophobia.

Subcommittee members evaluated these medications for safety and negative side effects, which included patients stopping the drugs due to negative side effects.

The subcommittee also evaluated the triptans to determine if there were any subgroups of patients in which one of the triptans was more effective or associated with fewer side effects. Subgroups were based on demographics such as age, sex, gender and race; if they are taking other medications; or those who had another disease at the same time.

Individual Differences

It's important to note that medical studies evaluate the overall effects of a drug on a group of people. Even when a study doesn't show that a whole group is helped or hurt, typically some people are helped and some people are hurt.

In choosing to recommend medical treatments to an individual, health practitioners consider that person's individuality including her or his medical history. You can use the conclusions presented here as a good foundation to start a discussion with your health practitioner(s) about what's right for you.

Drugs Reviewed

The following triptan drugs were included in an extensive review of the medical literature:

Almotriptan (available as brand name Axert)
Frovatriptan (available as brand name Frova)
Naratriptan (available as brand name Amerge)
Rizatriptan (available as brand name Maxalt)
Sumatriptan (available as brand name Imitrex)
Zolmitriptan (available as brand name Zomig)

Eletriptan (available as brand name Relpax) was approved for use by the FDA on 12/20/02 and was not included in this review. It will be included in future updates of the triptan report.

Conclusions

While the conclusions of the Oregon Health Resources Commission represent findings for most people taking one of these drugs, these findings may not necessarily apply to a given individual. You should discuss these findings with your health care providers, to find out which (if any) drug is best for you.

If you are taking a medication or deciding to take one, ask your doctor and pharmacist three simple questions:

Are there other drugs that are used to treat my condition?
If there are, how do other drugs compare to this one, for me?
If two or more drugs are equally effective and safe, how do the prices compare?

Major conclusions of the HRC subcommittee were that:

It appears that a 10 mg oral dose of rizatriptan is the most effective triptan, based on whether a person had pain relief or was pain free at 2 hours after taking a triptan plus had pain relief a 24 hours. The HRC ' s triptan subcommittee recommends that it be the initial triptan of choice for treatment of migraines after the symptoms have begun.
There is sufficient evidence to also include sumatriptan 100 mg and zolmitriptan 5 mg as effective for initial therapy for patients with migraine.
As it is well known that triptan therapy must be individualized, the triptan subcommittee strongly recommends that health plans do not require a person to change from a triptan that has already been found to be effective for that person.
Ready availability of alternate forms is necessary for patients who are unable to tolerate the oral route.
Naratriptan was found to be effective but not as effective as other triptans.
There were no published studies of almotriptan that met the criteria required by the Oregon Evidence-based Practice Center and the triptan subcommittee to be included in this review process.
Because of a lack of published studies about frovotriptan in the medical literature, it is not considered in this report.
Eletriptan was not approved for use in the United States until the end of 2002. It was not included in the list of considered medications for this round of subcommittee meetings but will be examined in the next update.
Further head-to-head comparative trials that measure the same endpoints are needed to more clearly define if there are significant differences in the safety of triptans.
There is no comparative evidence to assess differences in efficacy and safety between triptans in patients of differing race or ethnic group, age or sex.

Specific conclusions of the subcommittee were:

Evidence from head-to-head trials for pain-free results at 30 minutes does not reach statistical significance.
Evidence for pain relief at one hour is fair and favors rizatriptan 10 mg compared to naratriptan 2.5 mg, zolmitriptan 2.5 mg and sumatriptan 100 mg. And 5 mg of zolmitriptan is greater than 50 mg of sumatriptan.
Evidence for being pain free at one hour is fair and favors rizatriptan 10 mg over naratriptan 2.5 mg and 5 mg.
Ten mg of rizatriptan appears to be superior to other triptans in obtaining pain relief and freedom from pain at 2 hours.
Rizatriptan 10 mg, sumatriptan 100 mg and zolmitriptan 5 mg appear to be superior to other triptans in obtaining sustained pain relief at 24 hours.
There are no head-to-head trials that measure health related quality of life and productivity.
No studies have had side effects as a primary endpoint, but most report them.
The subcommittee did not find important differences between the triptans with regard to adverse events.
There is limited information about the comparative duration and severity of adverse events or about their impact on quality of life.
Patient surveys indicate that people with migraines are willing to endure significant side effects to achieve pain relief.
Side effects are not a swing factor in choosing a triptan for initial therapy.
There is no comparative evidence to assess differences in efficacy and safety between triptans in patients of differing race or ethnic group, age or sex.
There are clear medical reasons for some people not to use triptans, with no difference evidenced between triptans. Careful practitioner evaluation of prospective patients is required before prescribing.
Triptans are effective in treating menstrual-induced migraine.

Your Guide To Choosing A Triptan Drug in the Treatment of Migraines

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