sumatriptan

21 October 2024

Oxford Report on the “Best” Medications – Takeaways…

James Discoveries & Stats, Medications, News, Tips 0

Led by researchers at the University of Oxford, and published in the British Medical Journal, a new study compares migraine medications to find out which is “best”.

Well, they would not phrase it that way. Really, they were trying to judge which medications had the best results in good clinical trials. This is important, because information like this can tell doctors which medication they might want to try with “person X”.

But, of course, there is no “person x”. When a specialist recommends a medication, they should be aware of your medical history, symptoms, and even family history. Study co-author Elena Ruiz de la Torre said it well – “Migraine is a very personal disease”. As also quoted at NewScientist, migraine expert Dr. Peter Goadsby adds that these studies “tell you about a population, but they’re very blunt instruments for trying to understand what’s going on at an individual level.”

With that warning in mind, it is still helpful to have these studies, and here’s what they found.

The now “older” migraine medications, the triptans, are still great tools. In fact, in these studies they are beating out the newer CGRP related medications such as lasmiditan, rimegepant, and ubrogepant.

So the report gave great marks especially to eletriptan, and after that rizatriptan, sumatriptan, and zolmitriptan. Interestingly enough, the humble ibuprofen also got high marks in this report.

In other words, these were the medications that had the best evidence for getting rid of pain and having few side effects.

Again, remember that the newer drugs are helping people that did not respond well to the triptans. And there may be medications and treatments that are better for treating certain people with certain symptoms.

The authors summarize their conclusion based on the studies they reviewed:

Results on both benefits and harms should inform shared clinical decision making, considering the preferences of patients, caregivers, and healthcare professionals. Our findings should help inform future guidelines and updates to recommendations to ensure that patients receive optimal care. Overall, the results of our network meta-analysis suggest that the best performing triptans should be considered the treatment of choice for migraine episodes owing to their capacity for inducing rapid and sustained pain freedom, which is of key importance for people with migraine. While the recent introduction of lasmiditan, rimegepant, and ubrogepant has expanded options for the acute treatment of migraine, the high cost of these newer drugs, along with the substantial adverse effects of lasmiditan, suggest their use as third line options, after the less expensive, similarly efficacious, second line options such as ibuprofen, acetylsalicylic acid, diclofenac potassium, almotriptan, and frovatriptan have been considered.
Comparative effects of drug interventions for the acute management of migraine episodes in adults: systematic review and network meta-analysis

So the moral of the story? The general guidelines out there don’t seem to be far off, and this is no time to throw out the old just because we have the new. All things equal, if you’re thinking of trying a medication for migraine, talk to your doctor about the triptans. But be sure your doctor knows your situation. You are not “person x”.

Also see: Major study suggests best treatments for migraines

And from earlier this year: “Older” Migraine Meds on Trial: What Works?

And back to ibuprofen – NSAIDs – Which One Should I Take For Headache?

5 January 2024

“Older” Migraine Meds on Trial: What Works?

James Discoveries & Stats, Medications 0

Late last year a new study analyzed almost 4.7 million migraine attacks and the medications that patients took. According to those patients, which abortive medications actually worked?

The data was collected from patients’ responses on a smartphone app between 2014 and 2020 (which is why newer medications like gepants and ditans were not included in the study). Dosage was also not taken into consideration. Finally, the “baseline” was ibuprofun. In other words, which medications worked better than (or not as well as) ibuprofen?

However, as you can see, the sample size was huge. So which medications, according to patients, really fought back against an individual migraine attack?

It shouldn’t surprise too many that the migraine-targeting meds worked best:

Triptans (e.g. eletriptan, sumatriptan, zolmitriptan) were at the top of the list, working well 5x more often than ibuprofen.
Ergots (dihydroergotamine and ergotamine) were 3x more effective than ibuprofen
Anti-emetics (anti-nausea medications) were 2.5x more effective
Next came opioids, and NSAIDs (not including ibuprofen)

This is not to say that ibuprofen isn’t effective. It was still effective 42% of the time. And it roundly beat acetaminophen (paracetamol), which was effective 37% of the time.

But other similar NSAIDs other than ibuprofen may be worth trying – especially ketorolac, which came out as working 62% of the time, significantly more than its cousin ibuprofen.

Since triptans topped the list, which triptans tended to work the best? Well, it was the ones listed above, but not in that order:

eletriptan
zolmitriptan
sumatriptan

They were all considered effective over 70% of the time – and remember, triptans very much depend on the person, and also how they’re taken.

There’s no doubt that these “older” medications, even ibuprofen, are still helping a lot of people. Lists like this won’t necessarily tell you what will work for you. However, they do give you a place to start.

Your doctor will be able to take more of your personal medical history into consideration when recommending a medication. And there are also risks and side effects to consider, which also vary from person to person.

But if you’re a candidate for a triptan, one of the top three is probably going to be high on your doctor’s list. Tylenol, on the other hand, might be best left on the drugstore shelf, until you’ve tried some better options for migraine.

For the actual study abstract, you can go to Simultaneous Comparisons of 25 Acute Migraine Medications Based on 10 Million Users’ Self-Reported Records From a Smartphone Application.

For another more detailed analysis, check out Certain Migraine Medications May Be More Effective Than Ibuprofen.

14 October 2021

A Natural Alternative to Sumatriptan? (Your Questions)

James Information, Treatments 1

Is there a good natural alternative to sumatriptan?

First, an apology – I’ve been negligent in answering your questions. So today I’m going to tackle one from Vicki in the USA.

Vicki finds that sumatriptan helps fight her migraine attacks. But she’s wondering if there’s a “natural alternative” to sumatriptan that she can use when she doesn’t have any medication available.

It’s a great question, but not an easy one! For one thing, triptan medications such as sumatriptan don’t seem to act the same in every person. And sometimes even small differences (such as the differences between a generic and a brand name medication, or different “delivery methods” – tablet, nasal spray, etc.) can make a difference in how well it works. Also, triptans may help with various symptoms (nausea, pain, sensitivity to light).

So you’re probably not going to find a precise alternative that does the exact same thing in your body.

Another reason why the question is difficult is that sumatriptan, as an older and much-studied medication, is often compared with other treatments. Some of these studies are high quality, others not. But the short story is that there are actually a lot of alternatives. Basically, most of the good alternative treatments that you’ve heard about are probably worth a try.

It may surprise many people that there are excellent, often well-studied alternatives to medications. Many people still assume that a “natural alternative” is going to be inferior. But that may not be the case at all.

So, to get back to the original question, here are some possible alternatives that you may want to try. But, as with medications, it will be trial and error, and you may need a combination of some of the treatments listed.

Water and salt – Staying hydrated is a great way to avoid migraine. But you may find that you can lesson the symptoms of an attack with some water and a salty snack. If you feel that you’ve eaten something that is triggering the attack, drinking more water may help lesson the trigger effect.
Ginger Supplement – This is one of those studies I was telling you about. In a study published in 2014, researchers found that a 250mg dose of ginger was comparable (in some ways better) than a 50mg dose of sumatriptan. Ginger has been used for pain and nausea in other conditions besides migraine.
Heat and Cold – Experimenting with heat and cold (ice and heat packs) has long been a helpful migraine treatment, but as with anything it seems to work differently depending on the person and the migraine attack.
MigreLief-Now – A combination supplement specifically designed to fight migraine when the attack is starting.
“Starve and Sink” – This method is completely counter-intuitive, but it’s becoming more well known thanks to the work of Dr. Josh Turknett. You can read more here: How To End A Migraine Without A Pill (starve and sink, part 1), and then part 2 here.

A few more things to consider. First, here’s a brief list of “natural remedy” ideas that may help.

Second, it’s important to consider overall lifestyle changes and possibly supplements that may help prevent migraine. I’m thinking about things like magnesium, cutting down on sugar (part 1 and part 2), and proper exercise.

Finally, there are other medications that you may be able to have on hand to stop an attack, and you may be surprised how effective they are (if taken very occasionally). For example, the humble aspirin and ibuprofen. Ketorolac is another example of a simple anti-inflammatory that has been compared to sumitriptan.

Have you found a natural supplement that has helped fight a migraine attack in the place of sumatriptan? Leave a comment, and let’s help Vicki by keeping the conversation going.

8 May 2020

Which Medications are most recommended for Children and Teens with Migraine?

James Discoveries & Stats, Medications 0

These specific recommendations come from the American Academy of Neurology and the American Headache Society. A helpful summary was published at Practical Pain Management.

As with many such studies, the recommendations come from the level of “confidence” that we have based on the results of clinical trials. For example, as we’ll see under “preventatives”, amitriptyline (Elavil) is “high confidence” as a preventative, but propranolol (Inderol) is “low confidence”. That doesn’t necessarily mean that amitriptyline is amazing and the best or that propranolol is useless. It does mean that our data for propranolol is a lot more limited – although so far it looks quite promising.

Before even getting to medication, the article (Ask the PharmD: What are the recommendations for preventing and treating pediatric migraine?) quite rightly points to lifestyle changes. We could add to that other treatments, including biofeedback and certain supplements. It’s tempting to look at the most recommended medications and think that these are the most recommended treatments – that’s not the case. With children, as with adults, there are some excellent treatments that you’ll probably want to try before any regular medications (especially preventative medications).

So let’s start with abortive medications – which drugs are most recommended to stop a migraine attack once it’s started? Remember, this is different with every child, but at this point the most recommended include triptans – but not any triptan. Most recommended are zolmitriptan, and then sumitriptan. Also the combination of sumitriptan and naproxen. However, these are only recommended for ages 12 and up (many medications simply haven’t been adequately studied in younger children).

Ibuprofen is also recommended, and is the #1 choice for younger children (6 months and older).

Sumitriptan/noproxen and zolmitriptan were also recommended for the related symptoms of photophobia and phonophobia – that is, sensitivity to light and noise.

If the symptoms are serious and frequent, and other medications haven’t worked sufficiently, preventatives may be tried.

For preventatives, as mentioned earlier, amitriptyline was the “high confidence” choice, with topiramate sneaking in under “moderate confidence”. These were only listed for ages 10-17.

Remember, preventatives should be far down the list of things to try. Steady doses of medication and their side effects are not to be rushed into. Check this article for other reasons to be less than optimistic about preventatives for children: New Study Questions Preventative Migraine Drugs for Kids

Remember, these recommendations do not automatically mean that they’re the best choice for you or your child. If other medication has been tried but these have not, it’s probably a good place to start. But it will be worth the trouble to investigate other non-drug treatments, many of which have been very helpful for children and teens.

For more details, take a look at the article at Practical Pain Management, especially the last section.

10 September 2019

New Triptan Study (and is it really useful?)

James Discoveries & Stats, Medications 0

Triptans – medications that were specifically designed to fight migraine pain – come in a number of varieties. So, which ones are the most effective? A new study attempts to answer that question.

The study, published in the European Journal of Clinical Pharmacology, compared various triptan medications. Probably the most well known is sumatriptan, partly because it was the first one to come out years ago. But as we’re discussed in the past, sumatriptan doesn’t work for everyone. Some people who have not found it helpful at all have had great success with other triptans.

For more of an introduction to triptans, see 10 Triptan Facts You Need to Know Now.

So who was the “winner”? Surprisingly, it was eletriptan, a 40mg dose. The “loser” was naratriptan. Both of these were oral doses.

The difference between the two? Well, about three times more people were pain free at two hours with eletriptan than with naratriptan, so all the other triptans would fall between the two.

So – oral dose, you say. What about in injection? Or those nasal sprays? Aren’t they better?

Actually, they compared nasal sprays, oral, and subcutaneous (injections). Of course, most of the variety out there is with sumatriptan, so that’s where most of the information comes from. In short, the injections had the advantage of being quite a bit faster, but oral and nasal spray were about the same for effectiveness.

So just how useful is this information? Should everyone just run out to buy eletriptan? In oral form?

Well, there are some serious limitations with this study. As I suggested before, there’s a lot more information (and variety) for sumatriptan.

But perhaps even more importantly, there are some important reasons why one triptan may work for you and another may not. You may be taking other medications that could interact with a certain triptan. One may work better for women, or older patients.

So yes, maybe doctors and patients should pay a little more attention to eletriptan as a good option. Maybe you should even try it first (before other triptans, that is). But talk to your doctor, because she may have suggestions for you, far beyond “this happens to work better for most patients in clinical trials”. Everyone is different, with a different medical history and a different biological make up.

So how useful is this study? It’s worth raising an eyebrow and reconsidering what triptans we prioritize, as we look at it along with other trials. It also says good things about oral medications, and injections. But again, there are lots of other studies that say good things about nasal sprays – it depends on the person.

You can read the abstract here: Efficacy of triptans for the treatment of acute migraines: a quantitative comparison based on the dose-effect and time-course characteristics