Migraine Myth of the Month: Never use an oral and injectable triptan on the same day
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How this particular myth ever gained traction is something of a mystery, but a persistent myth it is.
As has been pointed out multiple times in previous issues of this magazine, migraine headache comes in all flavors, and because the intensity of migraine headache pain varies so greatly from episode the episode, and even within the same episode, it typically makes sense for the migraineur to have available several different tiers of therapy…with each tier intended for a different level of headache intensity.
As is pointed out in this issue’s “Migraine Treatment of the Month”, injectable sumatriptan remains the most effective self-administered medication for acute migraine headache of moderate to severe intensity…the most effective “rescue” therapy and the therapy most likely to help you avoid that dreaded trip to the ER. A migraine headache that is already severe or is rapidly escalating towards becoming severe requires a therapy with speed, and a medication’s rapidity of therapeutic action is linked to its Tmax. Injectable sumatriptan has a Tmax far faster than that of any orally administrated medication.
As is also pointed out in that article, injectable sumatriptan is not typically an appropriate therapy for use early in a migraine episode, when the headache still may be of mild to moderate intensity. In that setting Tmax is of less importance, oral medication is usually the treatment of choice, and an oral triptan is considered to be a first-line treatment.
Along with Tmax, one of the relevant pharmacokinetic variables discussed in the “Treatment of the Month” article is half-life. Injectable sumatriptan’s half-life is only 1 to 2 hours, and it will have largely passed from the body within only a few hours.
Let’s say you awaken in the morning with a migraine headache that already is fully developed and severe in intensity. You need speed. Knowing this, you reach for your sumatriptan auto-injector rather than your bottle of triptan tablets. Within 20 minutes the headache is much better, its intensity reduced to the point that you are able to move on with your day. As noon approaches, however, you can feel the headache beginning to return. It is still only mild in intensity, but you can feel it slowly building. What do you do?
Reach for your oral triptan. If you want to maximize its effectiveness, take it with a prescription dose of naproxen sodium and knock it down with a caffeinated beverage. Follow this with vigorous oral hydration using non-caffeinated beverages throughout the afternoon.
If you administered injectable sumatriptan earlier in the day, does that mean you must stick with oral sumatriptan to treat that early recurrent headache? No. A study conducted by your editor and his colleagues and published in the journal Headache clearly demonstrated that use of injectable sumatriptan and the patient’s preferred oral triptan within the same day is safe and associated with a high degree of patient satisfaction (Rothrock J, Morey V. “Mixing triptans”: patient satisfaction. Headache 2011; 51:135-140). If rizatriptan (Maxalt) is your oral “triptan of choice”, then by all means use rizatriptan to treat an early recurrence of headache following use of injectable sumatriptan. If a headache of mild to moderate intensity fails to respond to, say, rizatriptan plus ibuprofen taken together and is building to become severe, then administer injectable sumatriptan for “rescue”.
One caveat: allow 2 hours to go by between use of one triptan before taking another. This is more a matter of allowing enough time to pass so as to assess response to treatment than it is a safety issue. In fact, for those migraineurs who consistently experience early recurrent headache following subcutaneous administration of sumatriptan, there are headache specialists who recommend taking an oral triptan simultaneous with the injection. The logic: as the injectable sumatriptan is descending from its maximum blood level to exit the body, the oral triptan is coming on board to take its place. Such treatment is “off-label” but nevertheless makes a great deal of sense.
