S1 E5: Triptans

A National Migraine Centre Heads Up Podcast transcript


Series 1, episode 5

Heads Up is the award-winning podcast series on all things headache, brought to you by the National Migraine Centre.  Produced by leading headache doctors, it’s the trusted source of information and support for all those affected by migraine and headache.

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[00:00:00] Did you know migraine is the least publicly funded neurological condition compared with its economic impact? Let’s raise awareness together. Welcome to the Head’s Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.


Dr Jessica Briscoe [00:00:23] Hello, this is Dr. Jessica Briscoe, and I’m here with Dr. Katy Munro.


Dr Katy Munro [00:00:27] Hello.


Dr Jessica Briscoe [00:00:27] And today we’re talking about triptans. So all you need to know about triptans.


Dr Katy Munro [00:00:32] We’re going to cover everything, aren’t we, Jess? So first of all, triptans, many of you will have tried them, but quite a surprising number of people who come to the clinic haven’t even heard of them and don’t know what they are. So do you want to start us off?


Dr Jessica Briscoe [00:00:45] Yeah. So triptans were developed probably about 20-25 years ago now. They were the first specific migraine painkiller and they work on the serotonin system. So we know that serotonin is one of the neurotransmitters that’s involved in the migraine cascade. So they actually work to target that to cause some pain relief during migraine.


Dr Katy Munro [00:01:03] And they really have transformed some people’s lives. They were a big breakthrough when they were first invented. The first one invented was sumatriptan as an injection.


Dr Jessica Briscoe [00:01:12] Yes. Since then, there are now actually seven triptans, which is another thing that often surprises people.


Dr Katy Munro [00:01:17] They haven’t always heard about them and they don’t realise that if they have tried one and they haven’t liked it, that it’s worth going through some of the other ones and seeing whether one suits them better. So just starting off with sumatriptan, we know that it was originally an injection and you can still get it in injection form, as some people do, but probably more frequently people take it as a tablet.


Dr Jessica Briscoe [00:01:39] Yeah, it’s also available as a nasal spray, which tends to be quite useful in people who have a lot of nausea or vomiting, they feel that they can’t take a tablet.


Dr Katy Munro [00:01:49] Yes. And the nasal spray formulations can be quite useful if you want a quick acting nasal spray. The downside, I’ve found, is that they taste quite revolting. So sometimes that can be a problem if you are feeling quite queasy.


Dr Jessica Briscoe [00:02:02] That can actually make you sick in a lot of cases and some people say that that’s worse than feeling sick from taking a tablet. And also, interestingly, just because it’s a nasal spray, it’s not all actually absorbed intranasally anyway. A lot of it’s actually swallowed. So people sort of say it must be faster because it’s taken intranasally. Actually you still swallow it so in your stomach that’s not working, it won’t necessarily be faster.


Dr Katy Munro [00:02:23] That’s true. So sumatriptan, because it was the first one that we had available when it became a tablet, people could take 50 milligrams or 100 milligrams as a starting dose. And we now know the maximum daily dose is 300 milligrams and I often find people haven’t been told that.


Dr Jessica Briscoe [00:02:40] Well, no, it’s quite a big dose, actually, 300 milligrams.


Dr Katy Munro [00:02:43] They come in packets of six so that’s actually a whole packet. And not many people want to take six tablets because they really have given up on it by then. And they also come with a warning saying if it hasn’t worked, then don’t take another one and people get quite confused about that.


Dr Jessica Briscoe [00:02:57] Yeah, I think sometimes people are just sort of given the tablets and say this is for migraines sort it out yourself.


Dr Katy Munro [00:03:03] Yeah. So if sumatriptan does work well for you it is fine to take a maximum of 300 milligrams in a day, but you are going to have to get quite a lot on prescription from your GP and there are really probably some stronger ones available or ones that may work more specifically for you as an individual.


Dr Jessica Briscoe [00:03:20] Yeah, so I mean, when we’re talking about the different types of triptan, I think we tend to split them into ones that work quickly and ones that are a bit more slower acting. So the choice of it all depends on your type of migraine. So the fast acting ones, probably the two that I use more commonly apart from sumatriptan are zolmitriptan and rizariptan. And then there’s also eletriptan and almotriptan as well.


Dr Katy Munro [00:03:42] And the rizatriptan and zolmitriptan have those milk formulation tablets so some people really like those.


Dr Jessica Briscoe [00:03:49] Yeah. Again, people often think- mistake the fact that it’s dissolvable to think that it actually gets absorbed in the mouth. Again, it still all goes down to the stomach. But again, if you are someone that gets quite queasy during attacks, actually taking something where you don’t need some water, so you don’t have to have a big volume on board, you can take it when you’re out and about works quite a lot better, I think, than taking sort of a normal tablet.


Dr Katy Munro [00:04:13] Quite handy for those situations where you need rapid relief. And I think the other thing is about which formulation, it is sometimes appropriate to have a quick acting one if you’re in a situation, say you’re going in to give a presentation at work or you need to be back functioning very quickly to go and pick your kids up from school or something like that, then a rapid onset triptan can be really helpful. But actually they are also quite short acting so you may need to repeat the dose.


Dr Jessica Briscoe [00:04:42] I think that’s really important, as you said, feeling confident enough to repeat the dose again, usually about two hours for the fast acting ones if you’re finding that the symptoms have worn off.


Dr Katy Munro [00:04:51] I think all the triptans say you can repeat after two hours, but people get a bit worried that they’re going to overdose on them or take them too often. So be confident that it is in the product licencing that they can be repeated later on in day one and it’s better to get on top of your migraine on day one than to take a triptan on day one, but then have it return and the migraine is kicking off again on day two, and then you have to take another one and then on day three and it hasn’t really gone. So hit it with everything you’ve got on day one is my motto.


Dr Jessica Briscoe [00:05:20] And they’ve got the slower acting ones. So naratriptan, which I think people are prescribing more because they think it’s weaker, it’s not necessarily weaker, it’s just a slower onset. It lasts in your bloodstream for a lot longer, which means that it’s good for those migraine attacks that are a bit longer but it won’t hit you quite so quickly so you get a slower release of the medication. And frovatriptan, which I think is your favourite one?


Dr Katy Munro [00:05:41] Well, personally, it’s my favourite one, but I also think it can work very nicely. It does take a while to work, though, so you have to warn people that it’s going to probably take about an hour to an hour and a half to build up and work for their particular attack that time. But then it will still be there keeping on working over the next 24 hours where some of the others will wear off after four to six hours and you definitely need to go and repeat those. But frovatriptan is quite useful around menstrual migraine as well.


Dr Jessica Briscoe [00:06:09] So it’s not licenced for use in that which means that that’s not what its original purpose was. But we do- there have been some studies actually which showed you could either use frovatriptan or naratriptan, but frovatriptan came up as more significantly effective. So usually with menstrual migraine, you start treating it two days before your onset of migraines so usually about five days before your period. And you take it regularly for five days and it can actually work as a mini preventative.


Dr Katy Munro [00:06:34] It can be really helpful in that way, can’t it? And also, I don’t know if this is just my gut feeling, but I think the ones that are quicker onset, sometimes people get slightly more side effects and side effects can be a little bit scary with triptans if you do get them. So one of the known side effects is a feeling of pressure or tightness of the chest. And if you’re not warned about that, then people sometimes think that they’re having a heart attack. I personally took a fast release one once and thought I was going to collapse. It was really quite scary. And you know, I theoretically knew what I was taking, but so you may- because it goes into your system more quickly, may get side effects more quickly. But having said that, what I think is the big message about triptans is that it’s worth trying different ones because individual triptans have very different properties and individual people react unpredictably to different triptans. So we generally say work your way through them until you find the one that suits you best.


Dr Jessica Briscoe [00:07:31] I also think it’s worth not just giving up after one dose of triptans. So if you’ve tried it for one migraine- the advice is to usually try it for at least two migraines, because you may find that you’ve taken it a bit later in one attack and that’s why it hasn’t worked. So try each triptan at least twice.


Dr Katy Munro [00:07:44] When you’re talking to your GP about getting a triptan on prescription, one of the factors that we come across a lot is the cost. So they do vary widely in cost. You can buy sumatriptan under the brand name of imigran over the counter, but I think they only sell them in sort of packets of two and they’re quite expensive. Sumatriptan was the cheapest one. I’m not sure if it still is. I think the price has changed on that. But some of the others are really quite expensive. And the other problem recently is, as with quite a lot of different medications, there’ve been some supply and availability problems. So people who are used to taking one triptan have suddenly found that they can’t get that particular one. So you just need to be aware that that’s an issue. And hopefully just talking to your GP about what formulary they have in the practise, whether they’re allowed to prescribe certain ones and why you want that particular one, you should have a useful dialogue with your GP about getting the best one for you.


Dr Jessica Briscoe [00:08:39] And I think the other thing to talk about is people get a bit worried about using triptans as they’re based on serotonin and using them with other types of medication that also affect your serotonin levels, specifically, antidepressants. GP’s and patients get quite nervous about something called serotonin syndrome. So this is actually a largely theoretical problem that’s not really been proven in any studies that I’ve come across, where they worry that if you have too much serotonin on board, you can get some quite horrible symptoms and become quite unwell with it, actually. And there is a theoretical risk of taking triptans with certain antidepressants and actually amitriptyline, which is something we often prescribe for migraine prevention. And so there’s always that worry where people will say, you know, this came up as an alert when my GP typed into the screen. Generally speaking, we say it’s safe to use triptans alongside antidepressants as we’ve never I’ve never come across this problem.


Dr Katy Munro [00:09:33] I’ve never come across it either. And I think because you’re only going to be taking the triptan occasionally, it just doesn’t seem to be an issue. So the guidance about how often you should take a triptan is I generally say take it on not more than eight days in a month. And I think that’s an easy one to remember because that’s basically sort of roughly twice a week. But it doesn’t necessarily have to be twice in a week. It could be a two or three days in quick succession as long as your total in a month is not more than about eight because and annoyingly, the very thing that helped migraine, if you take them too often, they can give you a thing called medication overuse headache which is a more relentless chronic headache that comes and is triggered by the triptans themselves.


Dr Jessica Briscoe [00:10:17] And I think there are some, I mean, obviously they’re not the only things that can cause that. And generally speaking, you may find some months that you’re taking a few more than others. But I think a rule of no more than eight a month is a good one to have. And if you’re finding that you’re taking more than that, sort of over a period of three months or more and that you’re actually getting more headaches, it’s worth bearing in mind that the triptan could be causing it.


Dr Katy Munro [00:10:39] I was giving some advice to a patient recently about this, and she was saying that she was taking sumatriptan very frequently, practically every day. And we had a chat about it and she stopped taking them so frequently, and it actually quite quickly, her brain settled down. Her headaches stopped, and then she was able to go back to using them intermittently because her brain had cleared from the triptan use. So it is only really probably about four to six weeks of stopping them. You may need to come and get some more specialist help with that rather than just going cold turkey and stopping them, although some people do do that.


Dr Jessica Briscoe [00:11:14] Yeah, it’s quite funny, actually. You saying that reminded me about a patient- I’ve seen a few patients where their doctors have not quite understood about how triptans are used and they’ll say, well, if you’re having them a lot, take it regularly, so take it as like a preventative. And then wondered why that wasn’t helping. They should never be used in that way, taken every day to try and stop. Apart from that really specific example we gave for the five days of around the period.


Dr Katy Munro [00:11:37] The other thing sometimes- I quite often hear people saying, I was worried, I knew about medication overuse so I started breaking my triptans in half. And we say, please, please don’t do that, because it actually is much more efficient to use a higher dose on day one and you’re much less likely to get medication overuse than if you use a little bit on day one, a little bit on day two, a little bit on day three. And it seems to be that drip, drip, drip of triptans that irritates the brain over a number of days, don’t you agree?


Dr Jessica Briscoe [00:12:04] Yeah, definitely. I think the other thing I wanted to talk about a bit was triptans in pregnancy and breastfeeding, because this is something we get asked about a lot. What do you think about triptans in pregnancy?


Dr Katy Munro [00:12:14] I think people have been scared. And of course, it’s not ethical to be studying pregnant women and trying drugs out on them. So what we do is gather data retrospectively from people who’ve inadvertently taken a triptan and then found that they were pregnant. And all of that seems very reassuring. So I’m quite happy for people to take their triptans during pregnancy if they need them, with the same rules about, you know, counting carefully on the number of days per month.


Dr Jessica Briscoe [00:12:42] Yeah, and I think I’d say with the breastfeeding situation, if when GP’s or other doctors look it up in our book, the BNF, which is our Bible, it always says that people should pump and dump is what I think the phrase is.


Dr Katy Munro [00:12:55] Yeah. I hate that expression but I know what you mean.


Dr Jessica Briscoe [00:12:57] So they shouldn’t- they need to express and discard breast milk after they’ve used sumatriptan. On some studies that we’ve seen you don’t need to do that.


Dr Katy Munro [00:13:05] Quite old fashioned i think, yeah.


Dr Jessica Briscoe [00:13:07] The only one that I would avoid is frovatriptan during breastfeeding because it’s lipid soluble. So it might actually theoretically be around in breast milk and, because it’s a long acting one, it stays in the stream for a bit longer. So that would be the one that I would avoid during breastfeeding.


Dr Katy Munro [00:13:23] So sometimes migraine does go away very nicely during pregnancy, but unfortunately can return during breastfeeding so that is a factor. And, you know, triptans let’s face it, when they work nicely, they really shorten the duration, the intensity of the pain for a lot of people, don’t they? They’ve been an amazing leap forward.


Dr Jessica Briscoe [00:13:42] And I think the last thing we wanted to talk about was what about age-wise? Because a lot of people come to us and they say, my doctors stopped prescribing triptans because I’m now in my 60s, in my late 60s, what can I do about that? So triptans are only licenced up to the age of 65 and there are some special circumstances where you shouldn’t be using them so if you’ve got uncontrolled high blood pressure, known recent stroke, uncontrolled sort of heart problems as well and I think that’s largely why they worry about it when you’re older. I personally say if you’ve been taking triptans safely before that, and obviously this on an individual basis, have no blood pressure problems, no heart problems, you can cautiously continue to take them.


Dr Katy Munro [00:14:24] I think it’s hard, isn’t it, because your risk of heart disease increases as you get older. Some people have a higher risk, of course, if they smoke or have high blood pressure or a family history, or if they had high cholesterol, all of the other things that factor in to a risk of heart disease. And we know that triptans work by constricting blood vessels so that’s where the concern is, I think, is it? And so we just need to have a conversation about whether it’s safe or not. They’re not licenced over 65 but that doesn’t mean that we ban them completely. We just need to be thinking really carefully about what we’re doing and talking to patients about their individual risks. What about children?


Dr Jessica Briscoe [00:15:02] For children, again, the licencing. We don’t do studies on young children. Again, they’re licenced from the age of 12 upwards. And it’s sumatriptan that’s licenceed- is that licenced in slightly younger children as a nasal spray?


Dr Katy Munro [00:15:13] Yes, I think it is, and zomig is in the book as well. So in the BNF you will read Sumatriptan and zolmitriptan but actually, there have been quite a lot of studies worldwide looking at the use of all the different triptans and they all seem to be safe. But I think it is something you definitely need to be speaking to your own GP or come and see us at the National Migraine Centre, if you want advice. We love seeing kids here.


Dr Jessica Briscoe [00:15:36] We do.


Dr Katy Munro [00:15:36] Get them early, that’s our motto.


Dr Jessica Briscoe [00:15:38] So I think in summary, what we’re saying is triptans are great. Don’t just stop at one if you find that one hasn’t worked for you there are six more to try.


Dr Katy Munro [00:15:48] Yeah work your way through them.


Dr Jessica Briscoe [00:15:49] Absolutely, and think about if you’ve got a quick short onset migraine, how long they’re lasting, or if it is a slower one, because you may benefit from a slightly longer acting one.


Dr Katy Munro [00:16:01] So Charlotte spoke to one of our patients about their experience of trying different triptans and here’s what she had to say.


Charlotte [00:16:11] Hi Elvira, thank you for joining us on our podcast. I know you had an experience with triptans. So what have triptans been like for you?


Elvira [00:16:18]  I have a real triptan story. I avoided them for years. I was terrified of the thought of taking triptans. I’d read about them and the fact that they could cause you to have chest pain and because I’d had episodes of chest pain related to spasms in my oesophagus, I was terrified that taking a triptan would bring this pain on. My GP prescribed them for me and I was still too terrified to take them. I would lie in bed groaning in pain and still be just too scared to take them. I would take the packet out, look at it and then just put them away again. I just couldn’t face it. I also have nausea, vomiting and diarrhoea with my migraines so they can be very severe and go on for three days. So I have taken antinausea medication as well, so I would try and stick to that and my paracetamol but usually it was just a case of sticking it out, usually in the bathroom. I then decided that I would try them and I think I had a little bit of success, but I did have some chest sensations. I would feel very hot in the chest and I did not like that at all. So I took them very, very infrequently. I then did go back and see my GP and talk about the nausea and how I was finding it difficult to manage that. And that even if I did take domperidone and buccastem, I could still find myself vomiting. And then, of course, no medication was helping at all because nothing was staying down. Yes, so that was really unpleasant. But she did then prescribe me zomig nasal spray and said to try that. So I did know that different triptans work differently for different people so I thought, well, I’ll give it a go. I gave it a go for a few times and I wasn’t sure that it helped very much but I thought, well I am going to be trying this a bit more regularly so I put in for every prescription. I had a note back saying we’re really sorry, we can’t prescribe this for you anymore because it’s too expensive for the surgery. So we’re giving you zolmitriptan orodispersible tablets instead and I thought, hmm that won’t work. And I thought, I can’t imagine they’ll work. And with these, you open the packet, which is a little bit tricky because the tablet is sometimes a bit crumbly and you have to open it very carefully and then put it inside your mouth and let it just dissolve there. And they worked! I couldn’t believe it but they actually worked for me and I didn’t have any chest pain, so I felt a lot more confident about using them. And I’ve probably been taking them now for about a year and I’ve had much better control of my migraines. And then I have a little bit of a magic story, too, about them in that I thought that my migraines were these really terrible episodes where I’d be in intense pain and vomiting and had diarrhoea. But then I read something about migraines possibly starting in the neck and that the neck not necessarily being cause of migraine, but actually being a symptom, the first symptom. So I thought, you know what, I’m going to just try taking one of these zomigs and see if it helps. And it was just magic. I had this pain in my shoulder and my eye and it went away and I phoned my sister and I said, you won’t believe this, but I’ve taken a zomig and this pain has gone away. And then I said to myself, well, it was probably going to go away anyway. So I thought, you can’t just take triptans when you’ve got pain in your shoulder and a pain in your eye that isn’t necessarily a migraine. But I tried again and again it worked and I only had to have one and it worked. So this was just like unbelievable to me and it was wonderful. But on the other hand, I also thought I’m getting more migraines than I thought. Because these were actually migraines and I struggled on at work with them just thinking I had a pain in my eye or my shoulder or a bit of a headache but then I came to realise through trying the triptans for them that they were actually migraine and that this triptan worked. Now, when I get one of mine, what I call ‘traditional’ migraines, I now take an antinausea drug called domperidone and the zolmitriptan at the same time, and usually I find that that reduces the migraine. It doesn’t necessarily take it away, but I’m in much less pain than I was before. So I’d probably maybe rate it a six or a five instead of a 10. And I usually find when I’m having one of these traditional full blown migraine attacks that I need to take a second one, two hours later and that does work and helps keep the worst symptoms at bay. So I found that really successful. And finally, at the age of 60, after having migraines since the age of 11, I now have something that can sometimes stop it completely. And on the other hand, really helps and after my visit today, I’ve got some other things to try so I’m really feeling much more hopeful about migraine than I ever have in the past. And I’m really grateful to the migraine clinic for giving me all those suggestions.


Charlotte [00:22:20] Fantastic, so triptans for you…


Elvira [00:22:25] After all that fear about taking them has in some ways really helped me get some control with some of my symptoms. So that’s really good.


Charlotte [00:22:36] That’s fantastic. Well, thank you for sharing your story with the podcast I think everyone will really enjoy that so thank you very much.


Elvira [00:22:40] Thank you for helping me.


Dr Jessica Briscoe [00:22:45] Our next Heads Up podcast is focussing on migraine prevention, specifically lifestyle management.


[00:22:54] You’ve been listening to the Heads Up podcast. If you want more information or have any comments, e-mail us on info@NationalMigraineCentre.org.uk. Till next time.


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