How much sumatritpan (or another triptan) is too much?
How much sumatriptan (or another triptan) is too much is not clear. The initial FDA-approved daily dose of oral sumatriptan (Imitrex) for the treatment of an acute migraine was up to three 100 mg tablets. Several years later the maximum daily dose was reduced to 2 100 mg tablets a day, to be taken at least 2 hours apart. There was no scientific or safety reason for the reduction of the dose. Two other triptans, rizatriptan (Maxalt) and frovatriptan (Frova) are still allowed to be taken three times a day. The maximum dose of eletriptan (Relpax) is 2 40 mg tablets, however, in Europe it is 2 80 mg tablets. Some doctors are very strict in adhering to these arbitrary limits. Some patients will tell me that they always need to repeat the dose of a triptan 2 hours after the first dose. It makes sense to have them take a double dose at once and the results can be much better – the headache will go away and will not return. It is true that the higher the dose the more side effects you can expect. In patients who are sensitive to drugs or weight less than 100 lbs, it is prudent to try half of the usually dose and in everyone else the standard dose should be used at first. If the standard dose is not fully effective, another triptan can be tried, but if none provide sufficient relief and do not cause side effects I first recommend combining the standard dose of a triptan (100 mg of sumatriptan, 10 mg of rizatriptan, 40 mg of eletriptan, and so on) with an anti-inflammatory medication, such as Migralex (aspirin/magnesium), naproxen (Aleve), or ibuprofen (Advil). Only if this combination also fails would I suggest doubling the standard dose of a triptan.
What about the maximum dose of a triptan to be taken in a month? The initial studies of sumatriptan were conducted in patients who had 2 to 6 migraines a month and when the drug was approved by the FDA no monthly limit was imposed. However, the manufacturer packaged sumatriptan tablets in a blister pack of 9 tablets. This became the unofficial limit, even though no studies were ever conducted to examine the safety and efficacy of frequent sumatriptan (or any other triptan) use. Many doctors, including headache specialists believe that taking any abortive medication, including triptans too frequently will make headaches worse (so-called medication overuse headaches). We do have good scientific evidence showing that caffeine in fact can worsen headaches by causing caffeine withdrawal, or rebound headaches. People who drink large amounts of caffeine know that if they stop their caffeine intake they will develop a headache. In patients prone to headaches, as little as 2 cups of coffee, tea, or soda can worsen their headaches. We also have some evidence that barbiturates, such as butalbital (Fioricet, Fiorinal, Esgic) and opioid analgesics, such as codeine, oxycodone (Percocet), hydrocodone (Vicodin) and other can cause worsening of headaches if taken more than once a week. However, we have no evidence that triptans or NSAIDS, or non-steroidal anti-inflammatory drugs (Advil, Aleve, Motrin, Relafen, Voltaren, etc) cause worsening of headaches if taken frequently. Aspirin (such as in Migralex) in fact may prevent worsening of migraines.
I do discourage frequent use of triptans, which usually indicates poor control of migraines. Most patients with frequent migraine attacks are better off with preventive therapies, such as aerobic exercise, biofeedback, magnesium, CoQ10, Botox injections, or sometimes even preventive drugs. A common barrier to the frequent use of triptans is the insurance company. Many insurers have been reducing their monthly coverage of triptans from 9 to 12 down to 4 or 6, while increasing co-pays. This is clearly done not out of any safety concerns, but to save money.
With all of the above said, I do have about two dozen (out of thousands) patients who require very frequent or daily intake of triptans. These patients have gone through many of the preventive treatments listed above, including Botox, and they are still having daily headaches, or what we call chronic migraines. I usually try to have them stop triptans for several weeks to see if they improve with NSAIDs and prophylactic treatments, but most do not. These patients have very good control of their migraines, have no side effects, and can function normally. I am concerned about the potential cardiac side effects of these drugs, which are well documented. If a patient has some risk factors for heart disease (post-menopausal, high cholesterol, hypertension, diabetes, smoking, obesity, family history, etc), a stress test should be obtained.
What prompted this post was an article in the latest issue of journal Headache, which reports on a 49-year-old woman with 18 years of chronic cluster headaches. Injectable sumatriptan is the only treatment approved for cluster headaches. This woman has been injecting herself with 6 mg of sumatriptan anywhere from 2 to 37 times every day (on average, 20 times) for 15 years. She had no side effects or negative effects on her heart and there was no decline in the efficacy of sumatriptan over time. She failed several abortive and preventive medications. Other doctors have published articles describing patients taking triptans very frequently without loss of efficacy or side effects, but this patient has the most frequent and prolonged use ever reported.
Hearing loss, tinnitus – are they potential side effects
Been taking these three – Rizatriptan 10mg (~once a week to abort), Propranolol 80mg daily at night, Aimovig 140mg (monthly, 3 doses so far), and Magnesium Glycinate 400mg daily at night
Started experiencing increased ringing and some noticeable hearing loss in one ear.
There are no studies documenting that drug holiday restores the efficacy of sumatriptan and I have not seen this in my patients. I usually advise patients to try a different triptan (and we have 7 of them) or trying Ubrelvy or Nurtec instead.
I’ve heard that a “drug holiday” can restore sumatriptan effectiveness when it has waned over time. How long do you need to avoid sumatriptan to regain effectiveness? Can you use other non-triptan acute medications (e.g. Ubrelvy) during the “drug holiday” or will that negate the purpose of it? Thank you!
In 30 years on the market, sumatriptan has never been reported to cause hemangiomas. The monthly injections of biologic drugs for migraines (monoclonal antibodies) do not affect your immune system. However, they’ve been on the market for about 5 years while sumatriptan, 30 years. It is most likely that taking sumatriptan even daily is safer than injecting monoclonal antibodies.
I forgot to mention that for the last 10 years I take up to 17 sumatriptan 50mg tablets per month, every month. On average 12 per month.
I have migraines for 25 years. They started after my first child. I am 52 now and 1 year without my period. I was hoping to get rid of migraines with menopaus, but this is not the case (yet), but I still have some hope:-)
I take sumatriptan 50, once per day, on my migraine days.
At the begging i’ve had migraines only 2 days before and first day of my period. Never lasted more than 3 days. After cca 10 years migraines came also at the ovulation day. I took around 3-7 sumatriptans 50mg per month for 15 years.
But the last 10 years my migraines became more frequent, induced not only by hormone changes, but also with hunger, sleep deficiency, nuts, chocolate, change of weather and of course stress. I am very emotional person and everything affects me so much…
Sumatriptan is the ony drug that works for me. I’ve tried all NSAID’s, antidepressant, propranolol,… My doctor now suggests to try these new biological injections taken once per month. but I’ve heard that they destroy your immune system. Is this true?
The reason that I’m writing this post today is that I’ve had my abdomen ultrasound last week due to frequent stomach ache and gastritis I thougt…due to all painkillers for several years.
But the rsult of the ultrasound was that I have 4 liver hemangiomas sizes 6-12 mm, one liver cyst 1,2 mm and 8mm uterus mioma. The doctor advises to take control ultrasound check after 1 year.
I now wonder if is it possible that taking so much sumatriptan caused may liver hemangiomas to form? I’ve had abdomen ultrasound 15 years ago and nothing was seen. I am also concerned if these are really hemangiomas or is it possible that they are malignant? Should I double check with CT, MR?
I would really appreciate to hear you opinion. Thank you for any comment.
My daughter, now just over age 50, began migraines by age 20. Imetrix 100 mg helps. She tried to injectables, some help, but short low price trials end, & meds cost much too high. I read migraines as disability are second only to low back pain . Can Dr. M join with a long list of headache doctors, to ask the U.S. Government to increase low funding, to add more research dollars to this major life pain and disruption, to hope to bring more, better, lower cost solutions. There is much misery and lost enjoyment and productivity all across USA. Thanks for doing a public blog, Dr. Mauskop..jim
My migraines started when I was 19 years old. I originally used Ergotamine. It sometimes prevented an attack but more often only partially reduced the symptoms. Nausea and partial head pain along with sensitivity to sounds and light most often remained for several hours after taking Ergotamine.
As the years passed the frequency of the migraine attacks increased. What were monthly attacks now came weekly. I tried various other therapies including anti-depressants under the direction of a neurologist, 15 sessions of hypnotism with a registered hypnotist, 10 chiropractor sessions focused on reducing headaches and finally the elimination of all sweetened foods & coffee from my diet for over 2 years. None of these efforts had any positive effect on the intensity or frequency of my Migraine attacks.
As the years passed the frequency of attacks increased. I was having 3 or 4 attacks a week and it began to significantly effect my ability to work and play reliably. Around 2004 my doctor prescribed 100mg Imitrex tablets which worked quickly (20-30 minutes) and consistently. No lingering Migraine symptoms. For the first time in my life, I was able to completely abort the attack quickly & completely with no obvious side effects. I could not go indefinitely without having any break through symptoms. One tablet taken at the first indications of impending Migraine (I have no Aura) and all symptoms are quickly dissolved.
Unfortunately the frequency of Migraine attacks continued to increase. By about 2009 I was taking 5 to 7 100mg tablets a week to stop attacks. I was concerned that most public medical guides recommended a maximum of 10 tablets per month. I read that many Migraine sufferers were obtaining good relief at a 50mg dosage. So I began cutting my tablets in half. To my surprise, half the dosage was just as effective.
If I avoid those things that I have identified as direct antagonists, alcohol, chocolate and pot, I can reduce my triptan doses to 4 or 5 a week. One 50mg dose is effective 98% of the time. Two or three times a year I might need to take 2 doses for the same attack. Usually when I have not taken the first dose early enough.
In effect, I have been taking 50mg of Imitrex almost daily for over 12 years without any noticeable medical side effects. This almost daily dosing has improved the quality of my life immeasurably. I’m 76 years old and have no serious medical conditions. I also have no physical issues that that can be related to side effects of almost daily Triptan consumption.
I was pleased to find your blog today. It helps to calm my fears about almost daily dosing. I am also pleased that I can be living proof of your theory that daily Triptan dosing is likely benign.
Rob Cheply
We’d be happy to try to help – please call the office at 212-794-3550 or email admin@nyheadache to set up an in-person or a virtual appointment.
Praying someone can provide some helpful feedback or connect me to the doctor in this article and/or other helpful physicians. I am a 42 year old male with migraines for 30 years, somewhat stemming from head trauma, but I don’t think it was the cause, or at least not the reason I still have them and getting worse each year. They began as a one a week thing, lasting 18-24 hours and then I could expect to go about a week without another one. Once I started my career 10 years later, they were maybe once every 5 days, and I couldn’t afford to miss work once a week, so I started on triptans. They helped, but I also feel like I would get them more often, almost like I needed to experience the full migraine (often with vomiting) for my body to reset and go awhile without one. On top of getting them more frequently, I became more and more aware and sensitive to light and sound around me, not just when I had a migraine, but even when I didn’t, and it would eventually lead to a migraine and whatever side the stimuli was most pronounced. Now, I have daily battles with migraines, either enduring one, or trying to control my surroundings all of the time based on which side of my head one is developing. I’ve taken triptans for 20 years (mostly sumatriptan) and want to limit my use, so I try to go as long as I can without taking anything, but I usually end up paying for it and taking more of a pill anyway because my other attempts to alleviate it have failed. Are there ways to reduce the sensitivity to light and sound to prevent the mild migraine forming on one side and then potentially progressing to a full migraine if I’m not careful? Also, I would like a quicker working medication, unlike an oral pill which has to be digested and affect much of my system before it gets to my bloodstream at which point it might be too late anyway. An injection might help, or some sort of topical ointment to rub over the temple area that is experiencing the pain. I just need a way to reduce the pain more quickly and not have negative affects on the rest of my body. Thanks
I started sumatriptan in 1999 it was like a miracle. Back then I would get 1 a month. Now I get 15 – 25 a month. I live in Mexico and triptans are OAC and 2 – 3 bucks a pill for generic 100s.. If caught early 25 mg would work. I used suma until 3 years ago when zolmig became generic and switched. I was taking 2.5 mg at first and that worked good so I cut back to 1.25 mg and it worked! I still occasionally get the 4 AM nightmare and have to take up to 5 mg, once 7.5. I have less body ache from the zolma. Body ache and fatigue were the only felt side effect for either triptan in all these years. EKGs have been normal. I am 68. I am looking forward to trying the 24 hr 1/2 life triptan when it becomes available in Yucatan.
Yes, another triptan may not have the same side effect. It’s worth trying a few of the others – rizatriptan, eletriptan, naratriptan, zolmitriptan, and almotriptan. There’s also frovatriptan but it’s least effective.
Serotonin syndrome is very unlikely but it’s reasonable to avoid taking these two drugs at the same time.
I’ve had chronic migraines for the past 4 years but was only diagnosed about 6 months ago when they became daily. I take Gabapentin as a preventative and Magnesium Glycinate but I still have breakthrough migraines 1-2x per week. I was afraid of taking Imitrex more than once per week but this has calmed my nerves, so thank you!
I did wonder, is it normal for my entire body to hurt whenever I take it? That is not a normal side effect of my migraines, but since starting 100mg of Imitrex, about 30 min after taking it, my neck, jaw, and shoulders become significantly tight and achy. And then the rest of my body follows, though not as intensely as the neck/jaw/shoulders. I worry that I’m reacting badly and sometimes have to weigh whether the migraine or the Imitrex side effects will be worse.
If I am having this reaction every time I take the drug, would other triptans have the same effect or would it be a good idea to speak with my doctor about trying others?
Also, during one of these episodes (when I had a sudden migraine attack right after taking my daily Trintellix for anxiety/depression), I also became almost feverish and broke out in a sweat along with being in pain and feeling rotten. Could that potentially be serotonin syndrome? I have since tried to space out the time between when I take my Trintellix + Gabapentin and when I take Imitrex. If I take my daily meds then have a migraine, I try to wait an hour or two before trying the Imitrex, but I don’t know if that’s needed.
It is very common for migraines to be accompanied by neck pain. Neck pain can be the first symptom of migraine. Chances are, you have migraines with neck pain and not purely cervicogenic headaches.
Do CGRP drugs help to prevent Cervicogenic Headaches? I have tried seeing chiropractor, exercise, and stretching. When I took Ajovy ( which I now can’t get though my insurance) my headaches went away. Went from 10-15 a month to zero. Drinking alcohol is the only time I would get a headache. My headaches seem to get worse on imitrex. It helps the first headache of the month and then after I take it they get worse and worse. My headaches always start in my neck.
Tryptophan is very unlikely to cause serotonin syndrome. There is no evidence that tryptophan helps migraines, so it is not likely to replace sumatriptan (Imitrex).
A question: Generally speaking, is serotonin syndrome a risk if one wants to take lower dose of tryptophan if already taking Imitrex, and lower dose bupropion, daily?
Thank you for giving me some peace of mind since your 2012 blog on daily triptan use. I tried pretty much everything – many preventives, abortives, opiates, muscle relaxants, Botox, acupuncture, you name it, nothing worked – for what became daily migraine after being given fioricet and seeing the migraines increase. Doctors warned me I would have a stroke and die if I took Imitrex more than 2 times a week. I was in hell, on way too many Rx, so I finally ignored them, started buying Imitrex in Mexico, took it every day, and got my life back. I take 50 mg 1 to 4 times every day, but the amount I need has never increased except if I have a bad flu, etc.
I began daily triptan use in year 2000 and have never stopped. Intensity of migraines has decreased with menopause, and with treatment of Babesia and Lyme that I was diagnosed with 10 years ago.
however, I would love to stop taking it, but I have tried and failed due to unbearable excruciating pain. Opiates do nothing or make it actually worse, i.e. diluadid promoted one of the worst migraines ever. I am considering trying tryptophan wean off the Imitrex, mostly because I am moving far away from the Mexican pharmacies. But not sure tryptophan is a good idea.
Thanks very much for your blog.
Most people do not need to take an NSAID such as Advil with their triptan. Triptan can be very effective on its onw.
Dr. Mauskop- I’m so happy to have found your blog. I am a 50 year old female with migraines that were once 2-3x a month and now have increased to about 3x a week. I always assumed they were barometric pressure induced but now am thinking its perimenopause. My question is, when using a triptan is it always necessary to combine with NSAID’s or are there people who experience relief with just taking a triptan dose with nothing else? I was always told to take my 100mg sumatriptan with 4 advil. Thank you so much.
Your insurance may agree to pay for Emgality which is similar to Ajovy and also does not cause constipation.
I see that you do telemedicine visits and are accepting patients. My neurologist was going to try to get a vagus nerve stimulator for me but then they had their practice destroyed by one of our horrible fires in California. My GP put me on Ajovy but the insurance would only cover Aimovig which stopped my daily migraines but it caused constipation and when I tried to treat it I get constipation/diarrhea which is horrible! I have Behcet’s syndrome which might be the cause of the migraines or they might be independent they started at the same time when I was 16 so who knows. Imatrex was the only thing that worked without horrible side effects but having daily migraines, needing 2 Imatrex per migraine and getting 9 per month doesn’t work for me!
Yes, it is safe to take them together. Aspirin is not a vasodilator at all while triptans are only very mild vasoconstrictors. Vasoconstriction is not how triptans relieve migraines. We even have a drug combining naproxen and sumatriptan. It is called Treximet.
Is it safe to take a medication that contains aspirin with a triptans? If triptans are vasoconstrictors, and aspirin is a vasodilator, wouldn’t those be working against each other?
Thank you for your help, from a migraineur.
I have chronic daily migraines. For the last 20 years I have taken imitrex daily. I tell my neurologist don’t bother trying to take it away. I need it to work and live a life. So far I have had no side effects. All other daily regimen had helped. I am thankful every day for imitrex.
Serotonin syndrome is extremely rare and in my 30 years of practice I’ve seen only one mild case of it.
Thank you for replying. I am a smoker, but have recently started a medication in order to quit. The other concern I have is about the risk of serotonin syndrome from the triptans. I am on an SNRI medication for migraine prevention, and I know the use of triptans with other serotonin drugs greatly increases the risk of serotonin syndrome. I have read that it is rare, but that there have been instances of death from it. I wonder why doctors will prescribe these drugs when there is a risk of it, but I imagine the benefits outweigh the risks. Is serotonin syndrome from Sumatriptan something that should make me discontinue the use of any SSRI or SNRI medications? In 6 days I have used a total of 13 injections. I imagine it has now thrown me into a rebound cycle, nothing else works for me other than Imitrex though, and when you are in such severe excrutiating pain for days on end you become desperate. I have never experienced any worrying adverse affects from imitrex, i just thought that if you used more than 4 injections in a week that you could suffer a stroke or heart failure. It does make me feel better to know that others have used more than 2 in 24 hours. To read that lady has used more than 20 in a 24 hour period does surprise me, but we all react differently. I think it is the risk of deadly serotonin syndrome that worries me the most. Is this a rare occurence with triptans? Thank you so much for staying active in this thread, it is very comforting as I know most of us headache sufferers sometimes feel that no one takes our pain and suffering seriously, but I can see that you do Dr.M. I thank you for that.
Unless someone has other risk factors for heart disease, the risk of a heart attack from sumatriptan is extremely low. Those risk factors include smoking, high blood pressure, diabetes, high cholesterol, family history of early heart attacks, obesity.
I also use the sumatriptan injections for migraine. Usually they are very effective. However this week I have had a very bad one. Today is thursday and it started on sunday, so between today and sunday (5 days) I have used 12 injections. I know that is probably way too much and a waste as it is probably causing rebound, so over 5 days using 12 of the 6 mg injections, now I am paranoid and worried that it will make me have a heart attack. It does comfort me to know that other sufferers have had to use more imitrex than recommended, but now Im worried that I have had too much? I also read the half life of sumatriptan is like 2.5 hours. So over the past 5 days, alot of the imitrex should be out of my body? Migraine is so painful and horrifying that I think alot of us sufferers want the pain to stop so badly that we take the risks with these drugs, just to get a break from pain. Should I be worried that 12 shots in 5 day period is going to make me have a heart attack? Also am so exhausted from the pain I feel like I am not even making sense. I imagine this thread is no longer active, but hope to hear a reply
Hi Edna,
I am sorry to hear about your problem. Yes, I will be happy to see you and should be able to fit you in as early as next week. After the initial in-person visit we could have follow-up telephone consultations every six months.
Finding this blog has been a great comfort to me. I’m 81 years old and have had migraines since my early 20s, infrequently at first and by now chronic. My former doctor had me try every “preventer” including topiramate and propranolol, plus a couple of prednisone tapers and when nothing helped and I was getting daily headaches (sometimes two a day) he did the compassionate thing and authorized an “as needed” long term prescription for sumatriptan, which worked for me without any discrnible side effects and gave me a “normal life” for two years, 2017 and 2018, . Since that doctor retired I’ve been unable to find another doctor who will let me decide how much sumatriptan I need. One Physician’s Assistant has given me what is supposed to be a year’s supply of twelve 25 mg doses. Of course, it’s not nearly enough and I’m using them up “as needed”. I’ve had one Botox injection given by this PAC and am scheduled for a second one in mid-October – I’m told the second one often works better.
I am desperate! I live near Seattle Washington but am seriously considering a trip to New York. How soon could I get an appointment with you?
Hi, I read your post with great interest since I take triptans daily. I started with sumatriptan, then naratriptan and then eletriptan. Like the woman with cluster headache who has injected sumatriptan many times a day, I don’t get any side effects from eletriptan and they most often erase my migraine. Therefore it’s difficult for me to see the danger in using them.
I am 57 years old, my blood pressure is normal, even if it has increased by age. My migraine has mostly been hormonal which means it has decreased since I reached menopause and use Estradot patches. Now I mostly get migraine from weather changes, but I am very sensitive for those changes.
I started to use Cefaly in 2014 which decreased my intake of triptans, meaning less tablets a day. Since menopause, I also gave Saroten a new try and now it helps, a bit. I still take 20 mg Relpax/eletriptan almost every day, but sometimes, when the weather is stable, I can have weeks with half of the days without Relpax.
It happens that I get a kind of stubborn headache that simply just won’t go away even with Relpax. That is a new thing for me, it wasn’t like that ten years ago. When it happens I just stop taking medicine for half a day, then try again.
I think that I tolerate triptans well and that they don’t give me rebound headache, but that I might get some rebound headache from ASA+caffein. I find it very difficult to discuss this with my doctors, because their goal seem to be to make me fit in the box of tension headaches and rebound headaches, and I refuse to fit in that box. I feel a bit insulting that almost no doctor actually listens to what I say.
Thank you for writing this interesting blogpost.
An injection of 6 mg of sumatriptan (Imitrex) usually delivers all of the drug into the circulation, while 100 mg taken by mouth delivers only 14 mg. So, it possible that the maximum safe daily dose of injected sumatriptan is higher than 12 mg. In fact, some patients with severe cluster headaches who cannot find any other relief do inject much higher doses.
Dr Mauskop: I am a migraine sufferer. I read back to the initial post. Why is injectable sumatriptan limited to12 mg total in the label?
Unfortunately, many people do not tolerate magnesium. Yes, the usual dose is 400 mg of magnesium oxide, which is not well tolerated, but has the highest percentage of elemental magnesium. Chelated forms of magnesium, such as glycinate, gluconate, aspartate and other, have a much lower percentage of elemental magnesium, so the dose has to be higher. Some people do well with 2,000 mg of magnesium threonate.
Yes, drug holiday sometimes restores the efficacy of triptans. Also, magnesium deficiency can make triptans less effective, so if oral does not work, we give monthly infusions.
Thank you for the advice. I am taking magneisum but am a bit confused about how much to take. I have seen doses of 400 mg of magnesium cited but is this elemnatal magnesium? My supplement is magnesium diglycinate and it says 3g of that is equivalent to 300 mg of elemental magensium. However, I can’t tolerate 3 g due to getting GI issues. Can only tolerate about 400 mg of the diglycinate. I will get my RBC magnesium checked. Have had extensive workup for the burning mouth including B 12 but to no avail. Aimovig is not on the market yet but will be later in the year. Do you think after a “drug holiday” it’s likely the Relpax will work again? Have you seen that with other patients? I am desperate to have some idea about that. Thanks again
I would ask your doctor to check your vitamin B12 level with a related test, homocysteine for both burning mouth and migraines. RBC-magnesium is another blood test to ask for – half of migraine sufferers are deficient. About 80% do well with oral supplements, but 20% need a monthly infusion. In the US we have erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emglaity), three drugs given monthly by injection. They can be very effective. It is possible that one of them is available in Australia.
Just another comment further to my post below, I have not changed the brand of eletriptan I use. There are no generics available here so I have always used the brand Relpax, so that is not a potential reason for it ceasing to work. Any insight you can offer would be greatly appreciated.
Hi, I was wondering if you could provide some general advice. I have had chronic migraines for 26 years (now 45 yo) and have failed numerous preventative strategies including botox. I live in Australia and access to treatments and expertise in treating headaches is very limited here. I eventually found a triptan that was effective (Relpax – eletriptan) and was doing well aborting 2-3 migraines per week and using other analgesia in between. This reliably kept my pain at about a 2. Unfortunately I developed burning mouth syndrome last year and could no longer take the other medication due to the extremely dry mouth it gave me. In desperation I started using the Relpax every day and after about 4 months it stopped working well and after another 2 months it stopped working at all. I think I have either developed tolerance or rebound headaches from it or both. No other triptans work either and there are no other abortives on the market in Australia. Without an effective abortive treatment I am in 7-10 pain every day and have gone from being fully functional to not functional at all. I stopped taking the Relpax in early May although have used a few doses since to see if it has started working again. I know you can’t give specific advice to people who are not your patients, but my general question is have you had patients whose triptans stopped working and in time did they become effective again? I have seen 3 neurologists here and none had any idea. Thanks in advance
For many migraine sufferers, 400 mg of magnesium taken once a day (with food) is effective. However, if that causes stomach pains or diarrhea, taking 200 mg twice a day may work better, although we would first switch to a different salt of magnesium – magnesium glycinate, aspartate, threonate, etc. Some people do well with doses higher than 400 mg and they tolerate 400 mg twice a day.
Daily intake of magnesium often helps prevent menstrual migraines and PMS symptoms. Adding an NSAIDs, such as naproxen or ibuprofen can provide additional relief.
Is there a recommended way to take Magnesium ? I have started taking magnesium 2 months ago and it helped tremendously with my migraines. I only have 2 per month now compared to 8-10 migraines before. Is it better to take 200 gr in the morning and 200 gr at night?. Would taking Nsaids with magnesium during menstrual period help with migraines? thank you!
Unfortunately, I would need to get a much more detailed history and to examine you in order to be able to give you any advice.
Dr. Mauskop, I’m 68, headaches started about 5 yrs. ago. My headaches seem to be kinda atypical in that they are not debilitating, they start w/o aura and are like a hangover headache (i.e., I’m able to function but am in pain), if untreated the pain always lasts 24 hrs. I’m not a drinker. Was evaluated by neurologist, MRI normal, prescribed Sumatriptan which really helps. Does my particular type of headache tell you anything? Thank you.
The most likely cause of your muscle pain is muscle damage from what sounds like about two thousand injections. Fortunately, muscles and nerves that supply them can repair themselves but you need to start injecting sumatriptan into other sites – the other leg, upper arm, stomach, buttocks, even if it is a little less convenient. I would also have your doctor check for deficiencies of vitamins and minerals, which can contribute to pain. Most importantly, check RBC magnesium level (red blood cell as opposed to serum level), vitamin B12, and routine tests, including thyroid.
I used imigran injections for about 20 years about 100-120 times a year. I could always function with almost no problems and I m very glad with that. Since about one year I experience a pain in the muscle of my upper right leg. This is progressive when I m sitting in my car and when I climb a stair. By descending a chair I don’t feel anything.
Is there a relationship between triptan SC usage and the pain in my leg. I used the injections almost every time (100-120/year) in my right leg.
I would ask your doctor about acetazolamide (Diamox) for weather-related migraines. Here is my recent post about acetazolamide. Another drug to ask your doctor about is erenumab (Aimovig).
I have had migraines since I was 14 years old now 72. This last month has been hell for me, I have had 25 days of migraines . I know they are weather related. I started imetrix when I was 45. They have really helped me. Just wondered how many a month can I take before I should worry? I
Sometimes I can go 2 to 3 weeks without one. I refill my prescription once a month whether I need to or not so I can have back ups. Would love to try Botox but Medicare doesn’t cover. They seem to run in my family ,mother, sister, daughter and my nephews.
Physical exercise is a common trigger for migraine headaches. Slowly building up the duration and the intensity of exercise usually prevents these headaches. However, if even mild exercise brings on a headache, taking ibuprofen (Advil) or naproxen (Aleve) before exercise can be very effective (check with your doctor to make sure you do not have any contraindications for these drugs). This usually needs to be done for a couple of weeks and then exercise stops triggering a migraine. However, if this happens randomly and infrequently, you are limited to the treatment of the headache after it starts. If oral sumatriptan is not very effective, an injection of sumatriptan tends to work much better. Sumatriptan injections can be easily self-administered and work quickly – within 10-15 minutes.
Dr. Mauskop,
I only get migraines from exercise and take sumatriptan when I get an aura and it can dull the migraine slightly unless I vomit before its dissolved. Anyway, do you have any advice on how to manage my migraines? The only surefire way for me is to not exercise but that’s not realistic. I can expect migraines from heavy exertion like squats and deadlifts if I haven’t been slowly building up to them over a few months, but every other month or so I get a surprise migraine from very light exercise. For instance, yesterday I walked 3 miles with my pregnant wife and I barely consider that exercise but got a migraine that required 2 sumatriptan and I still have a residual headache that is keeping me from Sunday weekend plans.
Any advice is appreciated.
Yes, sumatriptan and other triptans sometimes cause increase in urination and a sense of dehydration. I cannot provide specific advice without seeing the patient first, but you can ask your doctor about the comments that are posted on this blog. I would also ask about preventive treatments, such as Botox and now, Aimovig – the new CGRP monoclonal antibody.
Dr. Mauskop: I am a 32 year old female. I have had increasingly frequent and worsening migraines for the last two years. I have been taking sumatriptan for the last year or so and it has been a life saver. Without it my migraines last 48 hours–severe pain and vomiting–unable to do anything. I’m concerned because the last five days I’ve had to take two (100mg ea) sumatriptans every day and the last two days I have woken up around 4am in so much pain, in the middle of a full blown migraine. When I take the sumatriptan that far into the migraine, it is not as effective. I’m scared to go to sleep now, because I do not want to wake up in this state. I saw another commenter say they took a smaller dose of sumatriptan each night before they went to sleep to prevent waking up in this state. Is that a good idea for me to try? If so, should I take a smaller dose than I would when I feel one coming on or take the full 100mg? Also, I drink 3-5 32 oz. bottles of water every day, yet still I’m waking up completely dehydrated. My mouth and my eyes are so dry and no amount of water or eye drops seems to help. Any recommendations for that?
Thank you!
Dr Mauskop,
I can’t thank you and everyone that contributed to your post sharing their experiences enough for speaking up about this problem. When you are told that you can only take two triptans per week, I don’t think drs realize the stress and havoc that that brings into our lifes. Just by trying to adhere to that rule, I think a lot of us get cephalgiaphobia, which triggers even more migraines. When you are in so much pain you can’t eat, excercise, work, do house chores, attend family and social events. It has such a destructive impact on your life. When triptans are the only thing that helps, you don’t have a choice but risk getting cardiac problems later on in life for some sort of normal life now. It’s so reassuring to hear that might not be the case after all. I appreciate you addressing this issue. I hope other drs can follow your lead on this.
Actually, Botox is very safe, very effective and the injections are not painful – you can watch me inject two patients in this and this youtube videos. Over the past 25 years I’ve treated thousands of patients with chronic migraines and my youngest was 8 and my oldest, 99.
I do occasionally prescribe Namenda, which is a drug for Alzheimer’s. It has few side effects, but it is not highly effective.
I would ask your doctor to do a blood test to check your “RBC magnesium’ level, vitamins D, B12, thyroid, and CoQ10 levels.
Hi Dr. Mauskop,
I’m so thrilled that I found this website! Thank you for all the great information.
I’ve been suffering with migraines for at least the past 10 years (start of menopause) I did get them at a younger age but the frequency is much worse now (about 15 a month) and every year I seem to get more.I’ve tried many preventatives and am unable to tolerate the side-effects. I take Relpax and Cambia and it does generally work but I obviously would like to get less of them. I haven’t tried Botox as I hear such mixed and generally not favorable opinions and also that its quite painful. What are your thought on the drug Namenda? Also, I’ve tried all the usual supplements with not much change.
Do you have any thoughts as to why they would be increasing in frequency? I have had an MRI/MRA and all checked out fine except many white spots.
I live in the Los Angeles area and was also wondering if you work with any Neurologist here that you would recommend. Thanks in advance!
I just did a search and could not find any reports of Imitrex (sumatriptan) causing tinnitus or hearing loss and I have never seen it in my patients. One possible reason for a reduced efficacy of sumatriptan is that some generic copies of the drug are significantly less effective than other. I wrote about this problem in a previous post. There are many generic manufacturers of sumatriptan and most of them are a little slower to dissolve than the brand, but still provide very good relief. All generics contain sumatriptan, however the difference often in the inactive ingredients that hold the tablet together – a few manufacturers produce tablets that do not dissolve well or at all, so they do not get absorbed and do not work.
I am 66 y/o and have taken 50mg of imitrex daily for about 10 years with no side effects. However, recently my headaches have worsened, and I am now taking 100mg a day, and sometimes up to 200mg a day. As a result I have developed a bad case of tinnitus (ringing in my ears). My friend said that her neurologist at UCSF warned her that imitrex can cause hearing loss. Have you found that taking imitrex daily can cause tinnitus, or worse, can it lead to hearing loss? Thanks for your reply.
Over the past 25 years triptans have been prescribed to millions of people (and in Europe, have been sold without a prescription) and no evidence of major risks has been discovered. The only exception is people with coronary artery or other vascular problems. I cannot give individual recommendations, but if you haven’t done this yet, I would discuss with your doctor trying the other 6 triptans – sumatriptan (imitrex), rizatriptan (Maxalt), naratriptan (Amerge), almotriptan (Axert), and frovatriptan (Frova). Frova is the only remaining triptan without a generic and insurance companies do not like paying for it. It is possible that one of these will have less side effects than Zomig. You will be a good candidate for the preventive treatment with CGRP monoclonal antibodies, the first of which (Aimovig) is expected to get FDA approval this summer or fall.
I’ve been disabled with migraines for over 20 years. I have daily migraines and take 1/2 of a 5mg zomiitriptan (zomig) when I have it. I have tried all the preventative RX and combinations of preventative RX, Nerve blocks, PT, Botox injections every 2 to 3 months the standard 32 injections to head, neck, face and shoulders, under went the Neuromodulation surgery with neuro-stim implants in my forehead and back of head, and got the daith ear piercing done. I had a sleep study and have sleep Apnea – so they thought that might be causing the migraines, but I sleep with my CPAP machine on every night and I still have the daily migraines. None of it has helped reduce my migraines. About 10 years ago they thought I was having rebound headaches from taking Zomig more than three times a week and I went through a week of detox in the hospital, but my migraines started back a week after I got out of the hospital. My question is would it hurt to take a 1/2 Zomig every night to try to prevent a migraine the next morning? I wish there was a rescue RX I could take that worked and had less side effects. Zomig gives me flu like symptoms for 2 hours after the headache pain stops. I take 60mg duloxetine delayed release at night for depression and it also helps me sleep. I also take 1 15mg meloxicam with the Zomig to help reduce the muscle and bone ache side effects. Any suggestions would be appreciated. A day without a migraine would be such a blessing.
For weather-related headaches, I recommend a free app, MigraineX, which sends an alert when barometric pressure drops by 20 millibars or more. It is more effective to take medicine at the time of alert and before headache starts. My patients take their migraine medication, such as Imitrex (sumatriptan) or an over-the-counter pain medicine, such as ibuprofen or naproxen. Sometimes these do not help and I prescribe Diamox (acetazolamide), which is also used for mountain sickness.
Topirimate was a miracle drug for me, reducing the frequency and duration of my migraines to maybe 1-3 a month at most and making them very short-lived. It had the side benefit of reducing my appetite, so I was able to keep my weight down. Then it stopped working, progressively, and I was weaned off of it while a migraine specialist has been trying other prophylactic meds. None of them have worked, either giving me GI problems or regular headaches. He has helped, however, by prescribing Imitrex and I have the pen and the tablets. The pen works much faster. My migraines, though, are now at over half a dozen a month–and almost always come with rain or thunder storms and changes in barometric pressure. I don’t like the potential side effects of Botox, especially the possible voice change since I am a singer. I’m very glad to read this information about dosage above because BCBS allows for many more tablets than pens. I have to save those for migraines that can put me in bed.
I would suggest printing out my blog post and a few comments to show your GP.
Hello, I am have difficulties in the UK because my GP is not happy with my triptan use – I use up to a maximum of 12 naratriptans per month. I am 51 and have had frequent migraines, both common and the type with brainstem aura, for 36 years. As far as I am concerned my migraines are stable and well-controlled; the pattern is a few more some months and a few less others, but generally i start 8-12 migraines per month, most of which I can get rid of within an hour or two with the triptans.
I have tried all the prophylactics (except botox) in the past, with no success; most recently on my GP’s insistence I tried topiramate, which was disastrous and gave me problems with speech, balance, vision and co-ordination. I do not understand why my GP is reluctant to give me triptans. except that she says she’s heard they can cause migraines (overuse) which I am very sceptical about. She wants me to stop triptans altogether to see what happens; I argue I cannot possibly do this as I need to earn a living (I’m a self-employed psychotherapist) and could not do so with two-three one to two day migraines a week; plus, surely the stroke risk is higher with frequent full-blown migraines?
Any comments would be much appreciated, and thank you for this article.
I would ask your doctor about trying sumatriptan injections, 3, 4 or 6 mg – they work much faster and are particularly useful when nausea accompanies the migraine.
What are the risks of taking more than 200 mg of Sumatriptan in a day? I take 100 mg pills for my migraines but the more severe headaches make me prone to vomiting. When that happens, I can usually take the first dose without problems and attempt to lay still until it kicks in or enough time has passed I can take another pill as needed. On more than one occasion, however, I’ve vomited soon after taking the second dose and am always conflicted about redosing. I’ve never had more than fifteen minutes elapse between when I take the pill and when I vomit and I’m always concerned that not enough time has passed for it to have properly been absorbed in my system. When is it safe to redose, if ever?
Yes, if you have daily migraines you may want to ask your doctor about trying naratriptan (Amerge), which often lasts longer and could work better than sumatriptan. Frovatriptan (Frova) is the longest lasting, but it is not available in a generic form, so it is very expensive.
Greetings Doctor.
So glad to see this thread. I will be calling bestdoctors.com Monday for a consult. There is no one I trust more. A question, daily imitrex 100mg, 6 a day provides some relief but it seems I am chasing the daily migraines. I literally have to set my alarm as if I sleep more than 3 hrs I’m in big trouble from the pain. I have gained 80 lbs over the past 8 months due to not being able to function. Current weight 280. I realize this is a risk, but could not manage the pain without the imitrex. You referred me to uc headache clinic for botox, but the earliest appointment is June. Would it be beneficial to try one of the longer acting triptans? I know this is a lot of info, I have dementia issues as well and it’s difficult to explain things. Sorry for the long winded post. I am scared and having trouble wheezing. Just trying to get some direction. Thank you for your time. I so wish I could just come there for botox, just not financially possible.
I have suffered migraines since the age of 18. Before that i had stomach migraines all through my childhood. I have cealiac disease and have some problems with all grains which is why I follow The gaps diet. However the gaps diet doesn’t seem to help with the migraines. But it improves my general health, which is why i persist.
I am now 49 years old and am post menapausal. All through my fertile years my triggers were mainly hormonal and could be timed accurately with mestration and ovulation. I had stress related ones too sometimes. During menopause i had a period of time ( 5 months) when i completely stopped menstruating and completely stopped having migraines… It was sheer joy! I hoped that menapause would mean the end of migraines. A few years on and they still come very much on a cyclical basis. I have been on preventatives for ten years but none of them seem to help me much and so recently i am just taking injections early on in an attack which nearly always aborts it. Sometimes i have to take two. I am getting them and aborting them up to 8 times a month.
I am slowing reducing preventative medications in favour of just taking sumatriptan injection to abort attacks. I like Petra L sometimes get a block of attacks close together and then i end up deciding to go through the 3 days agony of a full blown migraine, in the hope that i won’t get rebound headaches from taking too many. I feel as if my body has to have the attack to stop the increasing cycle. Then i will normally go for 4 weeks completely migraine free! It is very odd. It is almost like my body has to do it…. Like a person having an epeleptic fit or something.
In my mind, surely it is better to take an efficient 6 mg injection, thus avoiding my very sensitive stomach, than taking a 50mg tablet. Plus if the preventatives (anti depressant, anti convulsant and beta blocker) aren’t really working anymore, isn’t it better to stop taking a cocktail of drugs when sumaptiptans work 95% of the time.
I am spending about £80-100 pounds on sumaptriptan injections which luckily are available over the counter to buy in Brazil where i live.
I sometimes worry i am taking too many but without them my life, quite frankly, isn’t worth living.
Since resorting to just taking the injections i no longer take any pain killers of any sort.
For me this is huge progress. I have been aborting them for 5 months now but feel i may be due that 5% of the time that they don’t work.
This is the first time i have ever written about my migraines but i find myself increasingly educated by reading other peoples stories. Maybe mine can help someone too. 🙂
Thanks guys !
You should ask your doctor about trying a different triptan, such as eletriptan (Relpax), zolmitriptan (Zomig), or naratriptan (Amerge), but the most effective one would be sumatriptan (Imitrex) injection. Otherwise, a single dose of steroid, such as 8 mg of dexamethasone sometimes helps. If you are young and healthy, there no danger in taking the fourth dose of rizatriptan within 24 hours, but it is not likely to help if the first three did nothing.
Hello. I am having difficulty locating the information online that I am looking for. I’m wondering about Cambia. I have taken it on occasion with good results. Today I had a migraine and took 10-mg rizatriptan. Four hours later it had not subsided, so took another 10-mg dose. Approximately 4 hours after that still had no relief, and took another 10-mg dose. No relief. Four hours later I took Cambia, with no relief. Is there anything left I can take? I have Midrin, which typically seems to not do anything. I am desperate. What happens if I took a 4th dose of the rizatriptan? within the 24-hr period? Started with first dose at 5:00AM, and now its 9:30PM, so not quite been 24 hours.
Although even this much sumatriptan is not likely to cause heart disease, it doesn’t seem to be working well. Ideally, she should be getting a preventive treatment such as Botox, supplements or medications.
Dr. Mauskop,
My girlfriend is taking between 3-5 100mg sumatriptan pills per day. I know this is horrible for her heart and causing rebound headaches, what else is it damaging? She tells me I don’t understand how migraines fell which I don’t, but I am very worried. She sleeps all day and has mood swings. Please let me know.
Thanks,
Nick
I cannot give specific advice to anyone whom I haven’t seen, but as mentioned in my post on daily use of triptans and in many comments from readers, there is a small group of patients for whom daily use of triptans is the only solution which allows them to lead a normal life. There is no evidence of any long-term dangers of drugs like sumatriptan or rizatriptan, but having a daily severe migraine can be severely debilitating. While rebound, or medication overuse headache is uncommon with triptans, it is fairly common with opioid pain killers, such as hydrocodone. The ideal prophylactic treatment, which you haven’t listed, is Botox injections, although they are expensive if insurance does not pay for it.
As far as fighting the insurance for a larger quantity of Maxalt per month, the doctor can appeal the denial and speak to a doctor at the insurance company. However, doctors don’t get paid for sitting on the phone with the insurers, so many are reluctant to do it. You may want to go to GoodRx.com to get a coupon for a local pharmacy. I just checked – you can get 12 tablets for $26 and then you do not have to deal with the insurance. You do need an extra prescription from the doctor.
I am 70 yrs. old. I have had documented migraines since my mid-thirties. As I have gotten older I now get nearly daily migraines. I get them in early morning hours, i.e. 3:30 AM. I believe this is caused mainly by severe arthritis in my neck, which can trigger a migraine. Over the years I have tried beta-blockers, Topamax (for over 14 years) and all the triptans known to man. The one that works the best for me is the 10mg Maxalt. I have always been able to get my rx for 12 tablets in a month filled more than 1x in a month. Now, in the middle of 2016 I am fighting with my insurance (not Medicare D) for more than 1 refill in a month. The prior authorization submitted by my pain management doctor was denied today. The reason “a quantity of 30 tablets exceeds Citizens RX qualtty level limit of 12 tablets per 30 days. Chart notes indicate you are not on prophylatic therapy (e.g. propranolol, topiramate, valproic acid) to prevent migraines. You also take hydrocodone 7.5 mg every 12 hours for pain and function”
This is a new PBM insurance vendor, since Jan. 2016. Obviously they see none of my prior history of years and years of topiramate @ 100MG 2 x day. And of course they had no conversation with my physician, in fact, he was not aware I had been denied. I must now file an appeal…
My question to you Dr. Mauskop is this:
1. How bad is it to take 24-28 Maxalts in a month? I actually have been doing this for about 3 years (with no issue from refill requests within a month) I do not have heart problems, kidney issues and such. Just migraines and severe neck pain. I have had an epidural injection a couple of months ago and a nasal SPG done about a month ago. Epidural helped with neck pain, but now it’s back.
2. Do you have a suggestion as to how I am to fight this? My neurologist of 15 years retired in June. She was one who prescribed the maxalt, hydrocodone, and topiramate plus other drugs over the years. I go to a pain management doctor who is one trying to help me with this. His office is very aggravated about this.
3. Is it your assumption that a PBM insurance co. must have an actual physician that reviews the prior authorization requests and contacts the prescribing physician?
Thank you so much for your time in responding.
Yes, it is not unusual for a generic drug, such as sumatriptan (Imitrex) or rizatriptan (Maxalt) to be less effective than the brand or a different generic. You may want to try a generic sumatriptan made by a different company. By law, the manufacturer of the drug has to be listed on the label you get from the pharmacy. You may need to go to a different chain (CVS instead of Walgreens or Walmart) or buy it online. GoodRx.com is a good place to get a discount coupon for a local pharmacy for most drugs.
My 17 year old daughter is suffering terribly with chronic migraines – she has done every preventative drug that they can think of including botox injections – she takes the 100mg sumatriptan and never gets feeling any better than a 4/10 for pain and lately it isn’t even doing that well. Could the generic not be working as well? Should I ask for Imitrex instead?
Please call 212-794-3550
Dr. Mauskop, how do I make an appointment with you? I’m in NYC.
1. The only way to find out if you have MOH is to stop taking Imitrex for a couple of weeks, with or without steroids.
2. Yes, anxiety could result from Imitrex.
3. Yes, BOTOX and Topamax can help even MOH, so there is no need to get off Imitrex first, but there is no point taking Topamax again if it cause side effects in the past.
I am happy do a written consultation through BestDoctors.com if you have more questions.
Thank you for your response, Doctor. I wish I could come to your clinic in NY, but I’m in San Diego. Do you ever work with patients on a long-distance basis? I am very nervous about taking the steroids to treat the Imitrex MOH syndrome, especially a 3-week program. I am concerned that after the steroid treatment, my headaches will continue and I’ll be right back where I was with the Imitrex. For several months, I’ve taken 50mg of Imitrex at bedtime, even if I don’t have a headache. When I do that, I don’t wake up with a headache during the night or in the morning. I am usually headache free all day. If I don’t take it at bedtime, I always wake up at about 3-4am with a bad headache; and even if I take Imitrex then, the headache subsides but not completely. I know you’re not supposed to take Imitrex if you don’t have a headache, but this has been working for me. Questions:
(1) Does this sound like MOH syndrome to you?;
(2) Could taking Imitrex when I don’t have a headache at bedtime cause me to wake up with anxiety or other issues?
(3) Does Botox or Topamax help if I am taking Imitrex everyday or do I need to be off the Imitrex before trying the Botox? (I took Topamax for years in the past but I’m not sure it reduced my headaches and the side effects were too much for me.)
Thanks in advance for your response to my lengthy comments. I would happily pay for a telephone consult, if that’s a possibility. Kind regards, Nan
I’ve had patients on Imitrex complain of anxiety, but it’s been usually related to the worries about the risks of taking Imitrex or about having a migraine rather than due to the drug itself. Yes, a short course of prednisone can occasionally provide relief, but I never give it for more than 10 days.
Dr. Mauskop, Thank you for all the great information. I have been using Imitrex since the early 1990s, lately almost daily. If I take a 50mg pill before bed, I seem to be able to avoid having headaches. But, I’m wondering about some other side effects like anxiety. I have two questions: (1) Have you ever had any patients who complained about anxiety with daily use of Imitrex? (2) My doctor is recommending that I use a 3-week prednisone program (from higher doses to lower doses) to get off the daily Imitrex. Have you heard of this being successful in reducing the number of headaches (and Imitrex doses) each month? Thanks!
Good to hear you can take Sumatriptan frequently. I’ve had 30 years of chronic migraines 4-5 days a week and it changed my life when I finally got prescribed Sumatriptan 5 years ago. I take it most days and top up my prescription with ones I buy in India
I have had migraines for years and only in the past year have started taking sumatriptan. I get any where between 12-20 migraine days a month. I am often worried about the damage taking the sumatriptan on such a regular basis could be causing.
I’ve suffered for 50 yrs+ with Migraines (currently 58) and wasn’t diagnosed until 22 yrs ago. I’ve been on most meds and triptans were miracle drug for me. I am currently on 10 mg rizatriptan for acute migraine. I experience about 8-9/mo. Mostly triggered by barometric pressure changes which I can’t control. 1 tab relieves headache and lasts 24 hrs. If not for the triptan — I would not be able to work; so this therapy is a lifesaver. I find drinking caffeine with triptan helps my migraine. I drink caffeinated tea daily and have not been able to wean myself from caffeine. I was recently cut from 8 tabs to 4 tabs by my neurologist though I have no health risk other than age. I am very concerned what my options would be if triptans are taken away. I have had episodes where I’ve had to have 20-30 injections in my scalp/neck/sinus at one time to relieve headache episode (analgesic, steroid) – these worked well to arrest the episode and provide relief for 2 week period. I am glad to read that there is no evidence of risk for those who even take daily triptan. If I didn’t take the med, I would be nauseated and have to go to bed suffering for 2 days before the headache likely subsided. I did that for years and don’t want to go backwards.
It is not unusual to have increased urination after taking a triptan, but kidney damage from frequent use of triptans has never been reported. There is a report of two patients having kidney damage from triptans. These two patients were not taking triptans long-term and their kidney damage from an infarction (loss of blood flow) to a section of the kidney. Infarction of the heart, brain, and intestines has also been reported in patients who take triptans. Similarly, in these cases patients were not taking triptans long-term on a frequent basis, but only occasionally. These ischemic complications are rare and many triptans have been available over the counter in many European countries. Kidney damage is much more common in headache patients due to overuse of NSAIDs, such as ibuprofen, naproxen, and aspirin.
Dr. Mauskop, do you ever find problems with kidneys in patients taking daily triptans? I find they dehydrate me and have noticed my BUN is going up. (It’s still in normal range but the BUN/creatinine is now out of range.) I haven’t found any other cause for it. I’ve been taking 50 mg of Imitrex almost daily lately.
You may want to ask your doctor for a longer-acting triptan, such as naratriptan. Another option to try is to take Advil, Aleve or Migralex along with Maxalt. This could make it more effective and make the effect last longer.
I have episodic migraines, and take between the 8 and 14 Maxalts a month. They are effective. Sometimes the migraines keep coming back day after day. In that case I stop taking maxalts and suffer 48 hours through a bad migraine. After that I am free of migraines for 1 to 3 weeks. To me this is a very weird phenomenon. Should I just keep on taking Maxalts in case a migraine comes back every day and do not stop taking them?
Unfortunately, there have been no studies at all of daily intake of triptans, except for short courses for the prevention of menstrual migraines. I usually recommend a magnesium supplement (or even better, an IV infusion) since we’ve shown that 40% of cluster headache sufferers (and 50% of those with migraines) are deficient in magnesium. Magnesium is a natural calcium channel blocker, which is how verapamil produces its effect.
I have found that taking as little as 25mg of sumatriptan (tablet) nightly before bed prevents nightly cluster attacks, which otherwise occur about 25-28 days per month. This is after 3 GON blocks failed to affect them. I am also still taking 600mg (200mg 3x daily) of Verapamil but am prevented from increasing dosage due to extreme low BP. My doctor wants to send me for inpatient IV DHE but I am reluctant based on comments I have seen online. Wondering if there have been any updated research or studies since this article? Am being treated at UCSF.
I use triptans 2 50 mg each day, also use co/codamol 500 paracetamol 30 mg codeine with no side effects. I have just tried latest tms system – it did not work on me. 7 years i have suffered
Thank you for your comment and the link. It is good to see that the Danish Migraine Association is using common sense rather than just repeating what the FDA and the headache experts are saying. And indeed, what they are saying has no scientific evidence. In the US, both the professional and the lay organizations promote this damaging view that the triptans are a common cause of medication overuse headaches. We do have proof that caffeine causes medication overuse headaches. It is likely (but also not proven) that opioids (narcotics) cause medication overuse headaches, but NSAIDs, such as ibuprofen and naproxen and triptans are not likely to do that. Aspirin, in fact, may prevent worsening of headaches, but it is also lumped together with other abortive drugs. Yes, I’ve seen medication overuse headaches in a small number of patients triptans, but I also have seen many patients taking triptan very frequently and sometimes daily without having medication overuse headaches. For these patients frequent triptan use is a life saver. Many of my colleagues who strongly believe in medication overuse headaches from triptans admit that they also have patients who have failed preventive drugs, Botox, and other therapies and have no better alternative than to take triptans daily.
It is good to read that large amounts of triptans can be used with no particular side effects.
In Denmark (where I live) most doctors are strict in limiting the triptans to 9 per month. This leads to a large and undocumentet usage of painkillers, including codeine, which is not on prescription here. And subsequent medicine induced headache.
The established wisdom among the leading doctors in Denmark is that a detoxification takes 8 weeks with absolutely no medication (triptan, painkillers or preventive medicine).
We do not know how many loose their job because of medicine induced headache, but I hear from a large number via Facebook and the phone. And it is really difficult to find another job if you have to explain that you have been detoxed…
The Danish Migraine Association has stated its opinion (in English) here: http://www.migraeniker.dk/en/our-opinion/we-say/1359-9-triptaner-om-maneden
I sincerely hope that doctors throughout the world will reevaluate the limitations in triptan usage.
as many as 12 a month, but now they are only occasionaly, but at times I do have residuals.