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Migraine and undifferentiated headache 245
Serotonin 5-HT1 B/D agonists, collectively known as the triptans, are spe-
cifically targeted toward MH pathophysiology. Dozens of studies have
addressed varying formulations and administration routes of the triptans.
Sumatriptan is the best-studied agent for MH, although a burgeoning literature
(including large multicenter trials) demonstrates zolmitriptan’s safety
and efficacy. 21,22
Placebo-controlled trials have found sumatriptan to be effective via SC,
PO, IN, and PR routes. 23–29 Subcutaneous sumatriptan (6 mg), while more
effective than the PO route, is associated with a higher incidence of adverse
effects. 30,31 Perhaps sumatriptan’s best administration route is via the naris
(10 or 20 mg IN); this formulation causes few side effects and achieves
efficacy comparable to that of the PO preparation. 26,27 Preliminary evidence
suggests PR administration of sumatriptan (12.5 or 25 mg) is also efficacious
and has few side effects. 29
In addition to sumatriptan, many other triptans offer similar MH relief and
side effect profiles. 32,33 There is a substantial body of evidence supporting use
of zolmitriptan as a first-line agent. Administered by a variety of routes,
zolmitriptan achieves MH relief as fast as 10–15 min after IN administration
(of 5 mg). 34 Administration of an easily used orally dissolving tablet (of 2.5 or
5 mg) allows zolmitriptan to achieve MH pain relief in less than 30
minutes. 35,36 Zolmitriptan (2.5 mg PO) is also effective in menstruationassociated
MH. 37
Although the underlying literature is noted to be methodologically mixed,
both sumatriptan and zolmitriptan are recommended by various authorities
on pediatric MH. 38–40 One evidence review concluded that the data are
strongest for sumatriptan administered by the IN route; there is insufficient
data to conclusively recommend a 5 mg or 20 mg IN dose in children. 41
Some of the other triptans that are efficacious in MH include almotriptan,
eletriptan, frovatriptan, naratriptan, and rizatriptan. These agents appear
relatively equal in their relief of MH and associated symptoms such as nausea
and phono- and photophobia. 33
Like the antiemetics, the triptans are useful in myriad benign headache
syndromes. Clinical trial evidence from the ED demonstrates sumatriptan’s
equal efficacy in migraine, probable migraine, and tension-type headaches. 42