Vestibular Migraine Not As Rare As Once Thought
Vestibular Migraine was once considered rare, but it is increasingly becoming a more widely recognized diagnosis. This type of Migraine is characterized by vertigo and dizziness. It is a common cause of headache with dizziness, but VM can occur with or without head pain.
Only about half of all patients with VM experience pain with their attacks. It can be confusing to get a diagnosis of Migraine if you have no pain, but an accurate diagnosis is key to finding the right treatment and relief.
Who Should Take Triptans
Cove often recommends people whoâve only ever tried over-the-counter migraine remedies begin their treatment journey with triptan therapy . We use the word journey on purpose: Everyoneâs migraines are different, which means finding the best treatment plan for you might take time.
First triptan didnât work? Donât lose hope. We suggest trying at least two different triptans before ruling them out altogether. After all, despite all being in the same family, theyâre each a little bit different.
Medicines Plus Behavioural Therapy
An interesting research study published in 2010 compared two groups of people who had frequent migraines. One group took a beta-blocker medicine alone. Another group took a beta-blocker but also had a course of behavioural migraine management . BMM included education about migraine, helping to identify and manage migraine triggers, relaxation techniques and stress management. After a number of months the group of people who took the beta-blocker plus BMM had, on average, significantly fewer migraines compared with the group who took beta-blockers alone. Further research is needed to confirm this and to look at BMM combined with other medicines to prevent migraine.
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How Do I Use Triptans
Triptans work best when taken right at the beginning of the acute phase of the attack, or before the headache starts . If you use your triptan more than 1 hour after the onset of headache, the research suggests it will not work as well, and may not work at all.
Ideally, you should:
- Take one dose just as the acute attack starts, or if you know your migraine attack pattern well, just before it starts.
- If the attack goes away but comes back after two hours, you can take one more dose.
- DO NOT take more than 2 doses in 24 hours.
- DO NOT keep taking more doses as the attack progresses. This includes if your acute attack lasts more than 1 day do not take triptans on the second or later day.
- DO NOT take triptans on more than 10 days per month as it is a risk for medication overuse headache.
Remember, triptans are not painkillers. They will not work for a headache that is not a migraine, and will not work for other kinds of pain. Taking more if it doesnt work, as you might with painkillers, will not work.
How They Are Used
Because of their ability to short-circuit attacks, the ideal time to treat any migraine with a triptan is in the very early stages, when it becomes clear a migraine is unavoidable.
If the migraineur is experiencing an aura , it is preferable to wait until the headache begins.
Sumatriptan comes in tablets, a nasal spray or injection. The latter options are convenient as many migraineurs are unable to take down tablets due to nausea and vomiting once the headache begins.
Zolmitriptan, eletriptan and naratriptan come as tablets only, while rizatriptan is also formulated in wafers that can be dissolved in the mouth.
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An Overview Of Generic Triptans For Migraine
Jessica N. LeClair, BS in Pharmacy Studies, PharmD/MBA Candidate 2018
Jared L. Ostroff, PharmD, BCACPClinical Assistant Professor of Pharmacy Practice
Clinical Assistant Professor of Pharmacy PracticeWestern New England University
US Pharm. 2017 42:14-18.
ABSTRACT: Triptans, as combination therapy or monotherapy, are the first-line option for the treatment of migraine in adults aged 12 years and older. Currently, seven triptans are on the market that may be administered in oral, SC, and nasal formulations. Various trials have proven the efficacy of triptans for acute migraine attacks and compared tolerability between drugs within the class. Most triptans are available as generics however, pricing may become a challenge for patients experiencing more than three migraines per month, given the limits set by insurance companies. Adverse events commonly resulting from triptan therapy include feelings of tingling, numbness, warmth, and pressure or tightness in the chest and neck. The selection of triptan therapy should be individualized to the patients preference, comorbidities, risk of adverse events, and insurance coverage.
This article will summarize the role of triptans in the treatment of migraine, review evidence supporting their use, and discuss the cost, strengths, and formulations of available generics.
Medicines For Treatment Of Migraine Attacks
There are four types of medicines that are commonly used to treat migraine attacks:
- Ordinary painkillers – eg, paracetamol.
- Anti-inflammatory painkillers – eg, aspirin, ibuprofen
- Anti-sickness medicines – eg, domperidone, prochlorperazine
- Triptans – eg, almotriptan, naratriptan, sumatriptan, zolmitriptan
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What Triptans Does Cove Offer
Cove currently offers five generic oral triptans for migraine headaches: eletriptan, naratriptan, sumatriptan, zolmitriptan, and rizatriptan, which is available as a standard tablet or an orally-dissolving tablet . We chose these triptans because theyâre FDA-approved, fast-acting, and less likely to lead to side effects. Cove doctors usually prescribe sumatriptan first because itâs one of the most well-established and commonly used acute migraine therapies. If it doesnât work, however, your doctor may choose another triptan thatâs faster acting and potentially more effectiveâthough this recommendation will, of course, depend on your personal medical history.
We know this is a lot of information on just one possible migraine treatment option. Thatâs why we work with licensed physicians to help each and every person find a treatment plan that works for them. If youâd like to speak to a Cove physician about your headaches, simply .
If you’d like to keep exploring your options, we recommend reading about other proven migraine treatments: NSAIDs for pain relief and beta blockers, anti-convulsants, and antidepressants for preventative care.
The information provided in this article is not a substitute for professional medical advice, diagnosis, or treatment. You should not rely upon the content provided in this article for specific medical advice. If you have any questions or concerns, please talk to your doctor.
Taking Different Acute Migraine Medicines Together
It is possible to combine a triptan with a NSAID especially for people with longer lasting attacks or those in whom migraine attacks tend to recur.
Several combination medicines are available. The most commonly used contain aspirin or paracetamol combined with codeine, caffeine and/or an antiemetic. Paracetamol is generally not effective for migraine attacks but may be combined in some treatments to improve the effectiveness e.g. Migraleve, Migramax. However, it is best to avoid codeine and opiates in migraine treatment as their benefits can be short term, with dependency and medication overuse headache risks being high.
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How Do Triptans Work To Provide Migraine Pain Relief
Before we jump into how triptans work, let’s quickly recap what doctors believe causes migraines: For unclear reasons, in patients with migraines, nerves fire throughout the brain in a wave called a cortical spreading depression. This leads to changes in your brain’s blood vessels and inflammation, which ultimately causes headache pain.
Triptans work to alleviate migraines through a variety of ways. These include constricting blood vessels in the brain, slowing down inflammation, and blocking pain pathways.
Think of your migraine as a toddler having a temper tantrum and the triptan as a parent soothing them .
Table 3 Frequency Of Oral Triptan Side Effects
|3% to 4%||Less than 2%|
* Data from a meta-analysis of head-to-head trials, in C. Asseburg, P. Peura, T. Oksanen, J.a Turunen, T. Purmonen and J. Martikainen . Cost-effectiveness of oral triptans for acute migraine: Mixed treatment comparison. International Journal of Technology Assessment in Health Care, 28, pp 382-389. doi:10.1017/S0266462312000517.
** No head-to-head trials
Bold indicates superiority to sumatriptan 100 mg in high-quality head-to-head comparative studies.
All triptans interact adversely with ergotamine and dihydroergotamine , and they should not be taken within 24 hours of using an ergotamine drug. One triptaneletriptan should not be taken within 72 hours of taking medicines that inhibit a specific liver enzyme . They include the following:
- Ketoconazole and itraconazole , which are antifungals
- Nefazodone for depression
- Clarithromycin for bacterial infections
- Trileandomycin for pneumonia
- Ritonavir and Nelfinavir for HIV/AIDS
- Verapamil for high blood pressure
The physical effects of rizatriptan can be magnified when taken with the blood pressure medicine propranolol . Rizatriptan, sumatriptan, and zolmitriptan can interact with antidepressants called monoamine oxidase inhibitors , such as phenelzine , tranylcypromine , and isocarboxazid . Talk with your doctor about how to adjust your triptan dosage or whether to use another triptan in those cases.
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Triptans For Migraine And Headache
This page from Great Ormond Street Hospital explains about the medicines called triptans. Triptans are a group of medicines used to treat migraine or headache. They are also known as 5HT1-receptor agonists, which refer to the particular substance in the brain on which the medicines act.
Triptans do not prevent migraine or headache but they act on the pain once a migraine or headache has developed. There are several medicines in the triptan group including:
A Word Of Caution About Nsaids
Aspirin, ibuprofen , and naproxen
Be careful not to overuse these medications. Doing so can cause serious gastrointestinal problems including bleeding, ulcers, and potentially deadly perforations of the stomach, small intestine, or large intestine. To reduce the chance of those side effects, use the lowest dose that provides relief for the shortest time possible. Taking the medications with food may also help.
In addition, overuse of NSAIDs can sometimes trigger headaches, converting sporadic migraines to chronic daily headaches. You should tell your doctor if this happens. You will have to stop taking the medication for a period of time and switch to alternatives.
If your migraine headaches are severe, your doctor may still recommend that you try one of those low-cost drugs first. Some people with moderate to severe migraines respond well to them.
Most people who have moderate to severe migraines will probably need a triptan . This is especially the case if your migraines disrupt normal life.
For the simultaneous treatment of multiple possible causes of migraines, your doctor may recommend that you try taking a triptan with an NSAID. Treximet, which contains sumatriptan and naproxen, is the only such combination pill available. Studies indicate that it may be more effective than sumatriptan alone, but theres no evidence that it has an advantage over buying individual generic sumatriptan and naproxen pills and taking them together.
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When Should Triptans Not Be Used
Triptans can cause a mild degree of artery constriction due to its activity at the 5-HT1B receptor as discussed above. This could theoretically occur in narrowed arteries from cholesterol build up, such as in the heart. Therefore, triptans should not be used in patients who have coronary artery disease, cerebrovascular disease , peripheral arterial disease, or uncontrolled risk factors for these diseases because chest pain for them could truly represent heart attack. If there is concern for the possibility of underlying cardiovascular disease, a cardiac stress test should be performed prior to triptan prescription.
Patients that can not use triptans due to side effects, or if they have any of these medical contraindications noted above, should consider one of the newer types of migraine abortive medications available with either the gepants , ditans or neuromodulatory devices. Ubrelvy, Nurtec, and Reyvow are not triptans. These newer options often have a much lower side effect profile, can be taken in the setting of these medical contraindications to triptans mentioned above, and work by an entirely different mechanism of action.
Ive Tried A Triptan But It Didnt Work Or It Gave Me Too Many Side Effects
Everyone is different and its expected that medications work differently for each of us. If your migraine wasnt relieved by several trials, then your doctor may increase the dose, change to a different triptan, or switch to a different dosage form. During a migraine attack, some people experience a slowing of digestion. Therefore, oral medications may not be absorbed. Switching to a nasal or an injectable form may help. Additionally, some people find that taking an NSAID with the triptan may increase how well it works. You can also request a special mixture of sumatriptan and naproxen for convenience.
If you are finding that your current triptan is giving you too many side effects, you may want to switch to a longer acting triptan. These longer acting triptans include naratriptan and frovatriptan and are known for having fewer side effects. You should know that because these triptans are longer acting they are also slightly less effective at treating migraines. However, longer acting triptans may also reduce the chance that your headache will come back.
Lastly, if you have migraines that come on rapidly before medications have a chance to work you may want to consider changing to a triptan that will be rapid acting. Examples of these are the zolmitriptan nasal spray and the injectable or nasal spray version of sumatriptan.
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Symptoms And Features Of Vestibular Migraine
Vestibular Migraine can manifest through alarming symptoms like lightheadedness, ataxia, and sensations of moving while sitting still. Because symptoms are not the same for every person, it is incredibly easy to misdiagnose VM.
There are few clinical studies available on VM. Specialists in this field find themselves learning more every day about how to distinguish this diagnosis from other vestibular disorders like Meniere’s disease and benign paroxysmal positional vertigo .
Healthcare providers diagnose VM based on universal criteria set forth by the Barany Society and the International Headache Society. General practitioners receive little education in headache types, including Vestibular Migraine, so many people with symptoms of VM end up seeing several different doctors before they are accurately diagnosed.
Some of the common symptoms of Vestibular Migraine are:
- Memory loss and brain fog
- Positional and/or spontaneous vertigo episodes
- Sensitivity to light and motion
- Nausea and vomiting
Other Types Of Headaches
Some people experience visual disturbancesoften referred to as an aurathat may include flashing lights, zigzag lines, blind spots, or blurred vision. People also differ in how frequently they get migraines, the severity of the pain, and the speed at which the pain intensifies. We advise you to see a doctor if you think you have migraines. Even if self-medicating with nonprescription drugs is working for you, its worthwhile to get a proper diagnosis and have a doctor guiding your care. Also, it is not uncommon to need a prescription drug. You might choose to go to a neurologist or a clinic that specializes in headaches or pain, but many family doctors and internists have sufficient experience treating people who have uncomplicated migraine headaches.
And as we have previously noted, some types of migraineshemiplegic and basilar-typeare generally not treated with triptans. And only a doctor will be able to determine if you suffer from one of those rare types of migraines. As a general rule, anyone with a headache that is the first they have had, the worst, or associated with other symptoms, such as weakness or paralysis in an arm or leg, vertigo, ringing in the ears, or speech difficulties, should be evaluated by a physician.
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How Long Does It Take A Triptan To Start Working
We know that those two hours can feel especially long during a migraine episode, which is why we also recommend practicing self-careâwhether thatâs leaving work early and lying down in a dark room, drinking caffeine, or doing whatever it is that makes you feel better.
What Are The Treatment Options To Prevent Menstrual Migraine
Medications used to treat menstrual migraine are the same as those used to treat other forms of migraine. However, your doctor may recommend other treatments to be take regularly, in order to prevent or reduce the severity and frequency of menstrual migraines.
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What Are The Triptan Differences And Which Is Best How To Fine
- May 18, 2020
- 6:08 pm
Imitrex vs. Maxalt, Zomig vs. Maxalt, Amerge vs. Relpax, Frova vs. Imitrex, Maxalt vs. Relpax, Zomig vs. Imitrex, Frova vs. Amerge, Imitrex vs. Treximet. Maxalt vs. Frova. Axert vs. Imitrex. These are the triptans for migraine. There are 8 triptan types within the triptans medication class and include Imitrex vs. Maxalt vs. Relpax vs. Zomig vs. Frova vs. Amerge vs. Axert vs. Treximet .
So what are the best triptans to use? Well lets back up a little first. The ergot based medications such as DHE and cafergot have been the oldest migraine abortive medications used, which are still used today. However, they often have many side effects for patients and eventually the migraine specific triptans were developed for aborting migraine. Since 1992 , the triptans have been the first and only migraine specific abortive medications available up until 2020 when two new classes of migraine specific abortive medications have FINALLY become available with the gepants and ditans . These new migraine abortive medications can be read about in more detail here.