Migraine and Triptans
Posted: Nov 14 2016

Migraine Overview1,2

Headache is one of the most common ailments for which individuals seek medical attention.  Migraine is an episodic primary headache disorder characterized by severe pain that occurs in one area of the head and is often accompanied by nausea, vomiting, and sensitivity to light, sound, or odors.  The pain associated with migraines is so severe that up to 53% of individuals have reported severe disability or require bed rest during an attack.  In many cases, migraine attacks are preceded by an aura.  Auras are neurologic disturbances which may affect an individual’s balance, sensation, speech, or vision.  The physiologic mechanisms responsible for migraine headaches are not completely understood, although evidence suggests that swelling and inflammation of blood vessels in the central nervous system are at least partially responsible.  The prevalence of migraines is significant.  Studies have reported that 18.2% of women and 6.5% of men experience one or more migraine headaches each year.  The high prevalence of migraine headaches coupled with the potential for disability results in a substantial economic burden.  The indirect cost of disability to employers resulting from migraines is estimated to be $13 billion every year.

Migraine Medication Overview

Pharmacologic management of migraines is a multi-modal discipline with therapeutic options that span multiple medication classes.  Treatment can be roughly divided into two categories:  Preventive therapy and rescue therapy, the latter referring to treatment which stops an existing migraine attack.  Preventive medications include agents which typically treat other chronic conditions such as hypertension, depression, and seizures. Common rescue therapies are non-opioid analgesics, NSAIDs, ergot alkaloids, and serotonin agonists, which are commonly referred to as triptans.  Of all the rescue therapies, triptans are by far the most highly prescribed.  They are effective, well-tolerated, and available in a variety of strengths and dosage forms including tablets, injections, and nasal sprays.  Non-oral formulations are particularly important for this category since many migraines sufferers also experience nausea and vomiting as part of an attack. 

Triptan Overview1,2,3

Triptans are clinically appropriate for first-line rescue therapy in patients with moderate to severe migraine.  Sumatriptan (generic for Imitrex) is the original and most extensively studied agent and is reported to be up to 79% effective.  Second-generation triptans are comparable from a safety and efficacy standpoint, but vary in regards to their onset of action and duration of effect.  The effectiveness of triptan medications varies greatly amongst individuals and response to a particular agent cannot be predicted.  If a patient fails to respond to one agent they should switch to an alternative triptan and assess its effectiveness.  This process is repeated until a successful medication and dose is identified.

Common side effects resulting from triptan therapy are fatigue, dizziness, flushing, warm sensations, and parasthesias (described as numbness, tingling, or burning).  These side effects are typically not severe and are resolved quickly.  A small portion of patients (up to 15%) have reported chest symptoms including tightness, pressure, and/or pain.  Despite reports of such symptoms, adverse cardiac events are rare with triptan therapy.  Lastly, overuse of triptans has been linked to the development of a phenomenon known as medication-misuse headache, also termed as rebound headache.  As part of this physiologic process, the frequency of headaches can sometimes increase as a result of regular exposure to triptan medications.  In most cases, rebound headaches subside once overuse of the triptan is stopped.  It is for this reason that an optimal chronic migraine treatment regimen consists of both preventive and rescue medication therapies.    

Triptan Products

BRAND NAME(S) ACTIVE INGREDIENT (GENERIC) DOSAGE FORM(S) AVAILABLE (GENERICALLY)
Sumavel
Alsuma
Imitrex
Zembrace
Onzetra Xsail
sumatriptan Injectable
Injectable
Oral tablet, nasal spray
Injectable
Nasal powder for inhalation
Yes
Yes
Yes
Yes
No
Maxalt rizatriptan Oral tablet
ODT**
Yes
Amerge naratriptan Oral tablet Yes
Zomig zolmitripatan Oral tablet
ODT**
Nasal Spray
Yes
Yes
No
Axert almotriptan Oral tablet Yes
Relpax eletriptan Oral tablet No
Frova frovatriptan Oral tablet Yes
Treximet sumatriptan/naproxen Oral tablet No

MedTrakRx’s Cost Management Strategies

MedTrakRx currently offers two separate cost management tools for the triptan category:

  1. Quantity Limits - MedTrakRx recommends that all Plans implement quantity limits for triptan medications.  This strategy is consistent with the therapeutic role of these agents, since they are used on an “as-needed” basis and are not intended for daily use.  The established limits are consistent with FDA-approved dosing recommendations and are useful in preventing medication hoarding.
  2. Step Therapy – MedTrakRx’s suite of step therapy programs includes a triptan category.  As part of this program, members are required to try a less expensive generic alternative prior to approval of a more costly brand name triptan.  This program is beneficial for Plans seeking to increase generic utilization rates within this therapeutic category.

MedTrakRx’s Recommended Quantity Limits

DOSAGE FORM QUANTITY LIMIT
Tablet 9 tabs/30 Days supply
Nasal Spray 6 ml/30 Days supply
Injectible 3 ml/30 Days supply

References:

  1. Headache. In:  Kaplan J, Porter S.  The Merck Manual of Diagnosis andTherapy.  19th ed.  Whitehouse Station, NJ.  MerckSharp & Dohme Corp; 2011
  2. MinorD, Wofford M.  Headache Disorders.  In:  Dipiro, et al. Pharmacotherapy.  7th ed.  New York:  McGraw Hill;2008: 1008-1015.
  3. BajwaZH, Smith JH.  Acute Treatment of Migraine in Adults.  UpToDate,Waltham, MA.  Last updated Jun 1, 2016. http://www.uptodate.com Accessed October 11,2016.
  4. HawkinsK, Wang S, Rupnow MF. Indirect cost burden of migraine in the United States. JOccup Environ Med. 2007 Apr;49(4):368-74


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