Concerns about Triptans
My friend said she felt like she could not breathe when she took sumatriptan, and she ended up in the hospital for treatment.
I was told triptans could cause a heart attack?
Triptans are a class of medications specifically designed to treat a migraine attack. They are FDA-approved for acute migraine treatment, not migraine prevention. They are indicated for both migraine with and without aura.
Possible Side Effects
Fewer than ten percent of patients taking an oral triptans report one or more of the following side effects:
- Tingling of the skin
- Warm, hot sensation
- Burning or prickly sensation
- Feeling of heaviness
- Pressure sensation
- Feeling of tightness
- Dizziness, vertigo
- Dry mouth
- Headache (worsening before it improves)
- Muscle Weakness
- Pain in the joints or bones
- Feeling strange
- Tightness in chest, pain or pressure sensation in chest or throat
- Jaw discomfort
- Drowsiness, sedation and headache
- Lack or loss of strength
- Pounding heartbeat
- Pain or burning at injection sites (subcutaneous injection route)
- Bitter taste in back of throat (intranasal administration route)
- Discomfort in nasal cavity and sinuses (intranasal administration route)
Note that these side effects are all transient and usually subside within 15-30 minutes. Initially, the chest discomfort and pain, the tightness in the chest or throat side effects were believed to be cardiac in nature. The theory that triptan-induce chest sensations result from activation of serotonin receptors in the cardiac vasculature has not been supported by the research.
How it Works
Although so much attention has focused on a cardiac etiology, triptan-induced chest pain may actually result from esophageal spasm. Sumatritpan was shown to significantly alter esophageal motility in all patients without altering the ECG. Although data illustrate that triptans may have an effect on peripheral and coronary vascular tone, research and clinical experiences with these drug do not support an issue of triptan-induced cardiovascular morbidity and mortality.
The first triptan, sumatriptan, has been on the market since 1991 (25 years as of this writing). Triptans significantly reduce the pain of migraine within two hours for most people. They also have been shown to relieve other associated symptoms of migraine including nausea and vomiting, sensitivity to light and noise, and sensitivity to movement. Sumatriptan was the first of 7 triptans developed, and it is the most studied of these drugs. More patients report the unpleasant chest symptoms with sumatriptan.
All the other triptans have been compared to sumatriptan, and they have shown to have less bothersome side effects. Many patients tolerate the chest symptoms and other common side effects because they know that they are brief and transient (frequently limited to approximately 15 minutes), and that the benefit of complete relief from migraine pain and disability outweighs the tolerable transient side effects of triptans.
- Who should not take triptans? People who are at high risk for heart attack or stroke should avoid triptans. People with coronary artery disease (CAD), angina, peripheral vascular disease, uncontrolled high blood pressure, hemiplegic migraine, brain stem or “basilar” migraine, and people who have previously had a heart attack or a stroke in the past should avoid triptans. Also, someone with several high risk factors for heart disease or stroke, should consider other treatment options instead of triptans. Cardiovascular risks factors include: estrogen therapy, cigarette smoking, high cholesterol, uncontrolled diabetes, obesity, and a family history of early heart attacks or strokes. The American College of Cardiology and the American Heart Association have recommended guidelines for screening patients when considering prescribing triptan therapy. They recommend that patients with 3 or less modifiable (smoking, hormonal therapy) or treatable (hypertension, dyslipidemia, diabetes) risk factors can be safely prescribed triptans. Patients with four or more risk factors need close evaluation but are not necessarily precluded from triptan therapy.
- Symptoms of serotonin syndrome include skin ﬂushing, diarrhea, rapid heart rate, elevated blood pressure, confusion, dilated pupils, muscle rigidity, loss of muscle coordination, muscle twitching, headache, seizures and rarely, death. Because migraine is “co-morbid” with depression, many patients may be prescribed both a triptan for acute migraine treatment and an SSRI (selective-serotonin reuptake inhibitor) or SNRI (serotonin-norepinephrine reuptake inhibitor) for anxiety and/or depression. The simultaneous administration of two drugs that promote serotonin’s activity theoretically could produce an acute overabundance of the protein and a constellation of symptoms termed “serotonin syndrome.” Clinically signiﬁcant serotonin syndrome from simultaneous use of these medications appears to be extremely rare and may not be caused by the triptans at all, and the beneﬁt of adequate treatment for both migraine and depression appears to far outweigh the exceedingly low risk of dangerous “serotonin overload.” Because of this potential risk, the FDA issued a warning that implied doctors and patients should be wary of the co-administration of a triptan and an SSRI or SNRI. In fact, this warning was based almost entirely upon a theoretical concern and not upon clinical evidence or scientiﬁcally derived clinical evidence.
Choosing the Right Medication
It is important to point out that non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprophen (Advil and Motrin) and naproxen (Aleve) are used without a prescription to treat migraine headaches and they have a black box warning because they can cause serious cardiovascular, gastrointestinal and renal (kidney) problems. People self-medicate with these medications daily without any concern for the serious risks. Over 16,000 deaths per year are attributed to NSAID use. These drugs pose a much higher morbidity (illness) and mortality (death) risk than triptan use in appropriately screened patients.
Controlled substances, narcotics, opioids, and barbiturates, are not migraine-specific. They are also not FDA-approved for migraine treatment. They do not target the migraine pathology. They increase the risk of addiction and dependence and research has shown that they increase a person’s risk of transforming to chronic migraine even when taken infrequently. Drug overdose is the leading cause of accidental death in the US. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers in 2014.
It is important when choosing a migraine attack medication to use the best medication for the job. That should be the medication with the highest degree of efficacy (meaning it works well and it works fast) and the lowest side effect profile (side effects may be a nuisance to the patient but still tolerable) and safe.
Triptans are migraine-specific attack medications with a very good safety record over the past 25 years. The overwhelming majority of patients that take triptans never report side effects. Most of the unpleasant side effects are transient and tolerable. The possible benefit of taking triptans is the complete resolution of the migraine attack, decreasing disability and the burden of migraine on the individual and society, and mitigating the risk of transforming from episodic migraine to chronic migraine.
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