Thread by @SSNeuroMD

A conversation I have every week in @yaleneurons resident clinic: let's talk triptans. A basic approach for all you #neurotwitter and #medtwitter folks who aren't board certified in headache medicine 🤯but see these patients- just like me!

This topic is dear to my heart b/c I have migraines and let me tell you- migraines. are. awful. My life was changed when I got triptans. Gimme some suma + high dose NSAIDs = 😃 But not all triptans are created equal! If your patient fails one, it doesn't mean you're out of luck.

Let's say you start with sumatriptan 50mg PO (my usual starting choice) and the patient has side effects. What should you do?

My strategy would be to switch to eletriptan. And here's why: triptans have different half-lives and different times to peak effect. Suma has higher potency but also more side effects. If you switch to a smoother med like ele, the patient may get benefit without s.e.

All the way to the right you see nara and frova- nara has a half-life of 6 hrs and frova > 24 hrs! Not only do these meds have less side effects, they also are great if the patient has rebound, i.e. the suma works but then the headache comes back.

That's why we like to use nara or frova for "pulse" therapy in pts with status migrainosus or predictable migraine clusters (e.g. catamenial)- they take BID dosing usually with nsaids/reglan for 5 days and they don't rebound.

So what about the column all the way to the left?

What, you don't remember??? This one!

This is my favorite column b/c it's the "nothing works" column. It's the "my migraines don't respond to any pills" column. Sometimes pills just don't work and you have to bypass the stomach! Enter nasal spray or SC injection- FTW!

That's all folks! Certainly not everything there is to know about triptans (med overuse, side effects, contraindications.....topics for another day) but hopefully some helpful tips for you all. Interested in any headache specialist's POV!