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  • MIGRAINE HEADACHE MEDICATIONS
    • NOTE: This page is intended to be a quick reference for properties of commonly used migraine medications. It is NOT a comprehensive review of each medication. Other drug interactions, side effects, precautions, and contraindications may exist for each drug.

TRIPTANS ERGOTAMINES MIGRAINE REVIEW

OTHER RECENT STUDIES



Drug Dosage form Dosage Generic/Price Other Mechanism of Action/
FDA-approved indications
Side Effects
P = % of patients on placebo
who experienced side effect
Drug Interactions Precautions/
Contraindications
Almotriptan

(Axert®)
Axert® - tablet
  • 6.25 mg
  • 12.5 mg

Comes in dose pack of 6 or 12 tablets
Migraine headache

  • Adolescents 12 - 17 years
    • Initial: 6.25 - 12.5 mg
    • May repeat in 2 hours if needed
    • Do not exceed 25 mg in 24 hours

  • Adults
    • Initial: 6.25 - 12.5 mg
    • In adults, the 12.5 mg dose tends to be more effective
    • May repeat in 2 hours if needed
    • Do not exceed 25 mg in 24 hours

With strong CYP3A4 inhibitors
  • Initial: 6.25 mg
  • Maximum: 12.5 mg in 24 hours
  • Avoid concomitant CYP3A4 strong inhibitors in patients with kidney or liver disease
  • See CYP3A4 for a list of inhibitors
Axert®
YES/$$$$
(12 tablets)
Other
  • May take without regard to food

Pharmacokinetics
  • Time to max level: 1 - 3 hours
  • Half-life: 3 - 4 hours
Mechanism of action
  • Triptans are serotonergic agonists that have a high affinity for 5-HT1D and 5-HT1B receptors

  • The mechanism by which they alleviate migraine headaches is not completely understood. Proposed theories include the following:

    • Cranial vasoconstriction
    • Inhibition of vasoactive peptide release
    • Blockade of neurotransmitter release in the dorsal horn
    • Facilitation of descending pain inhibitory systems [1]

FDA-approved indications

  • Acute migraine headache with or without aura in adults and adolescents
NOTE: Side effects listed are for the 12.5 mg dose

Adolescents 12 - 17 years
  • Somnolence - 5%, P - 2%
  • Nausea - 3%, P - 0%
  • Dizziness - 3%, P - 2%
  • Headache - 2%, P - 1%
  • Paresthesia - 1%, P - <1%

Adults
  • Nausea - 2%, P - 1%
  • Dry mouth - 1%, P - 0.5%
  • Paresthesia - 1%, P - 0.5%
  • Ergotamines - DO NOT COMBINE. May cause prolonged vasospastic reactions. Do not use within 24 hours of each other.
  • Other 5-HT1 agonists - DO NOT COMBINE. Triptans should not be taken within 24 hours of other 5-HT1 agonists including other triptans.
  • SSRIs/SNRIs - triptans are serotonergic medications, and they may increase the risk of serotonin syndrome when taken with SSRIs and SNRIs
  • CYP3A4 strong inhibitors - almotriptan is a CYP3A4 sensitive substrate. When taken with a strong CYP3A4 inhibitor, starting dose should be 6.25 mg and daily dose should not exceed 12.5 mg. Avoid concomitant CYP3A4 strong inhibitors in patients with kidney or liver disease.
  • Cardiovascular disease - triptans have the potential to cause coronary, cerebral, and peripheral vasospasm. Because of this, they should not be used in patients with known cardiac ischemia, cerebral ischemia (TIA and stroke), or peripheral ischemia (bowel ischemia, intermittent claudication, etc.). Patients at high-risk for having vascular disease (e.g. diabetics, smokers, obese, etc.) should also use caution.
  • Prinzmetal's variant angina - DO NOT USE. Triptans may exacerbate vasospastic heart disease.
  • Hemiplegic or basilar migraine - DO NOT USE
  • Wolff-Parkinson-White syndrome and other accessory pathway conduction disorders - DO NOT USE
  • Chest pain and tightness - triptans may cause a sensation of pain and tightness in the chest, neck, and/or throat. These symptoms are more common with injectable drug forms. In most patients, triptan-induced chest pain is not thought to be caused by ischemia and is generally not serious. [1,4]
  • Raynaud's syndrome - triptans may exacerbate symptoms of Raynaud's syndrome
  • Hypertension - triptans may cause a short-term rise in blood pressure. Use caution in patients with uncontrolled hypertension.
  • Cardiac arrhythmias - in a small number of patients, life-threatening arrhythmias have been reported within a few hours of taking triptans
  • Serotonin syndrome - serotonin syndrome has occurred in patients taking triptans. The risk may be higher when taken with other serotonergic medications.
  • Medication overuse headache - overuse of headache medications including triptans (e.g. ≥ 10 days a month) may cause an increase in headache frequency and worsening headache with drug withdrawal.
  • Vision changes - rare cases of vision changes and vision loss have been reported with triptan use
  • Anaphylactic reactions - cases of anaphylaxis including angioedema have been reported in patients taking triptans
  • Sulfonamide sensitivity - almotriptan contains a sulfonyl group. Patients with sulfonamide allergy may also have an allergic reaction to almotriptan.
  • Ophthalmic effects - in rat studies, almotriptan was found to bind to melanin in the retina. In another study, almotriptan was associated with corneal opacities in dogs. In both studies, very high doses of almotriptan were used. The significance of these effects in humans is unknown.
  • Liver disease - starting dose should be 6.25 mg. Do not exceed 12.5 mg in 24 hours.
  • Kidney disease
    • CrCl < 30 ml/min: starting dose should be 6.25 mg. Do not exceed 12.5 mg in 24 hours.

Drug Dosage form Dosage Generic/Price Other Mechanism of Action/
FDA-approved indications
Side Effects
P = % of patients on placebo
who experienced side effect
Drug Interactions Precautions/
Contraindications
Eletriptan

(Relpax®)
Relpax® - tablet
  • 20 mg
  • 40 mg
Migraine headache

  • Adults
    • Initial: 20 - 40 mg
    • May repeat in 2 hours if needed
    • More patients responded to the 40 mg dose in trials
    • Do not exceed 80 mg in 24 hours
Relpax®
NO/$$$$
(9 tablets)
Other
  • May take without regard to food

Pharmacokinetics
  • Time to max level: 1.5 hours
  • Half-life: 4 hours
Mechanism of action
  • Triptans are serotonergic agonists that have a high affinity for 5-HT1D and 5-HT1B receptors

  • The mechanism by which they alleviate migraine headaches is not completely understood. Proposed theories include the following:

    • Cranial vasoconstriction
    • Inhibition of vasoactive peptide release
    • Blockade of neurotransmitter release in the dorsal horn
    • Facilitation of descending pain inhibitory systems [1]

FDA-approved indications

  • Acute migraine headache with or without aura in adults
NOTE: Side effects listed are for the 40 mg dose. Only side effects that occurred at an incidence greater than placebo are listed

  • Dizziness - 6%, P - 3%
  • Somnolence - 6%, P - 4%
  • Weakness - 5%, P - 3%
  • Paresthesia - 3%, P - 2%
  • Dry mouth - 3%, P - 2%
  • Upset stomach - 2%, P - 1%
  • Difficulty swallowing - 2%, P - 0.2%
  • Chest tightness - 2%, P - 1%
  • Abdominal pain - 2%, P - 1%
  • Ergotamines - DO NOT COMBINE. May cause prolonged vasospastic reactions. Do not use within 24 hours of each other.
  • CYP3A4 strong inhibitors - DO NOT COMBINE. Eletriptan is a CYP3A4 sensitive substrate. Concomitant administration can lead to increased exposure to eletriptan. Eletriptan should not be taken within 72 hours of a CYP3A4 strong inhibitor.
  • Other 5-HT1 agonists - DO NOT COMBINE. Triptans should not be taken within 24 hours of other 5-HT1 agonists including other triptans.
  • SSRIs/SNRIs - triptans are serotonergic medications, and they may increase the risk of serotonin syndrome when taken with SSRIs and SNRIs
  • Cardiovascular disease - triptans have the potential to cause coronary, cerebral, and peripheral vasospasm. Because of this, they should not be used in patients with known cardiac ischemia, cerebral ischemia (TIA and stroke), or peripheral ischemia (bowel ischemia, intermittent claudication, etc.). Patients at high-risk for having vascular disease (e.g. diabetics, smokers, obese, etc.) should also use caution.
  • Wolff-Parkinson-White syndrome and other accessory pathway conduction disorders - DO NOT USE
  • Prinzmetal's variant angina - DO NOT USE. Triptans may exacerbate vasospastic heart disease.
  • Hemiplegic or basilar migraine - DO NOT USE
  • Chest pain and tightness - triptans may cause a sensation of pain and tightness in the chest, neck, and/or throat. These symptoms are more common with injectable drug forms. In most patients, triptan-induced chest pain is not thought to be caused by ischemia and is generally not serious. [1,4]
  • Cardiac arrhythmias - in a small number of patients, life-threatening arrhythmias have been reported within a few hours of taking triptans
  • Hypertension - triptans may cause a short-term rise in blood pressure. Use caution in patients with uncontrolled hypertension.
  • Raynaud's syndrome - triptans may exacerbate symptoms of Raynaud's syndrome
  • Serotonin syndrome - serotonin syndrome has occurred in patients taking triptans. The risk may be higher when taken with other serotonergic medications.
  • Medication overuse headache - overuse of headache medications including triptans (e.g. ≥ 10 days a month) may cause an increase in headache frequency and worsening headache with drug withdrawal.
  • Vision changes - rare cases of vision changes and vision loss have been reported with triptan use
  • Anaphylactic reactions - cases of anaphylaxis including angioedema have been reported in patients taking triptans
  • Kidney disease - no dose adjustment necessary
  • Liver disease
    • Mild-to-moderate (Child-Pugh A/B) - no dose adjustment necessary
    • Severe (Child-Pugh C) - has not been studied. Not recommended.

Drug Dosage form Dosage Generic/Price Other Mechanism of Action/
FDA-approved indications
Side Effects
P = % of patients on placebo
who experienced side effect
Drug Interactions Precautions/
Contraindications
Frovatriptan

(Frova®)
Frova® - tablet
  • 2.5 mg

Comes in dose pack of 9 tablets
Migraine headache

  • Adults
    • Initial: 2.5 mg
    • May repeat in 2 hours if needed
    • Do not exceed 7.5 mg in 24 hours
Frova®
YES/$$$-$$$$
(9 tablets)
Other
  • May take without regard to food

Pharmacokinetics
  • Time to max level: 2 - 4 hours
  • Half-life: 26 hours
Mechanism of action
  • Triptans are serotonergic agonists that have a high affinity for 5-HT1D and 5-HT1B receptors

  • The mechanism by which they alleviate migraine headaches is not completely understood. Proposed theories include the following:

    • Cranial vasoconstriction
    • Inhibition of vasoactive peptide release
    • Blockade of neurotransmitter release in the dorsal horn
    • Facilitation of descending pain inhibitory systems [1]

FDA-approved indications

  • Acute migraine headache with or without aura in adults
NOTE: Side effects listed are for the 2.5 mg dose. Only side effects that occurred at an incidence greater than placebo are listed.

  • Dizziness - 4%, P - 3%
  • Headache - 4%, P - 2%
  • Flushing - 4%, P - 2%
  • Fatigue - 3%, P - 2%
  • Skeletal pain - 3%, P - 2%
  • Dry mouth - 2%, P - 1%
  • Hot or cold sensation - 2%, P - 1%
  • Ergotamines - DO NOT COMBINE. May cause prolonged vasospastic reactions. Do not use within 24 hours of each other.
  • Other 5-HT1 agonists - DO NOT COMBINE. Triptans should not be taken within 24 hours of other 5-HT1 agonists including other triptans.
  • SSRIs/SNRIs - triptans are serotonergic medications, and they may increase the risk of serotonin syndrome when taken with SSRIs and SNRIs
  • Cardiovascular disease - triptans have the potential to cause coronary, cerebral, and peripheral vasospasm. Because of this, they should not be used in patients with known cardiac ischemia, cerebral ischemia (TIA and stroke), or peripheral ischemia (bowel ischemia, intermittent claudication, etc.). Patients at high-risk for having vascular disease (e.g. diabetics, smokers, obese, etc.) should also use caution.
  • Wolff-Parkinson-White syndrome and other accessory pathway conduction disorders - DO NOT USE
  • Prinzmetal's variant angina - DO NOT USE. Triptans may exacerbate vasospastic heart disease.
  • Hemiplegic or basilar migraine - DO NOT USE
  • Chest pain and tightness - triptans may cause a sensation of pain and tightness in the chest, neck, and/or throat. These symptoms are more common with injectable drug forms. In most patients, triptan-induced chest pain is not thought to be caused by ischemia and is generally not serious. [1,4]
  • Cardiac arrhythmias - in a small number of patients, life-threatening arrhythmias have been reported within a few hours of taking triptans
  • Hypertension - triptans may cause a short-term rise in blood pressure. Use caution in patients with uncontrolled hypertension.
  • Raynaud's syndrome - triptans may exacerbate symptoms of Raynaud's syndrome
  • Serotonin syndrome - serotonin syndrome has occurred in patients taking triptans. The risk may be higher when taken with other serotonergic medications.
  • Medication overuse headache - overuse of headache medications including triptans (e.g. ≥ 10 days a month) may cause an increase in headache frequency and worsening headache with drug withdrawal.
  • Vision changes - rare cases of vision changes and vision loss have been reported with triptan use
  • Anaphylactic reactions - cases of anaphylaxis including angioedema have been reported in patients taking triptans
  • Kidney disease - no dose adjustment necessary
  • Liver disease
    • Mild-to-moderate (Child-Pugh A/B) - no dose adjustment necessary
    • Severe (Child-Pugh C) - has not been studied. Use caution.

Drug Dosage form Dosage Generic/Price Other Mechanism of Action/
FDA-approved indications
Side Effects
P = % of patients on placebo
who experienced side effect
Drug Interactions Precautions/
Contraindications
Naratriptan

(Amerge®)
Amerge® - tablet
  • 1 mg
  • 2.5 mg

Comes in dose pack of 9 tablets
Migraine headache

  • Adults
    • Initial: 1 - 2.5 mg
    • May repeat in 4 hours if needed
    • Do not exceed 5 mg in 24 hours
Amerge®
YES/$$
(9 tablets)
Other
  • May take without regard to food

Pharmacokinetics
  • Time to max level: 2 - 3 hours
  • Half-life: 6 hours
Mechanism of action
  • Triptans are serotonergic agonists that have a high affinity for 5-HT1D and 5-HT1B receptors

  • The mechanism by which they alleviate migraine headaches is not completely understood. Proposed theories include the following:

    • Cranial vasoconstriction
    • Inhibition of vasoactive peptide release
    • Blockade of neurotransmitter release in the dorsal horn
    • Facilitation of descending pain inhibitory systems [1]

FDA-approved indications

  • Acute migraine headache with or without aura in adults
NOTE: Side effects listed are for the 2.5 mg dose. Only side effects that occurred at an incidence greater than placebo are listed.

  • Nausea - 5%, P - 4%
  • Paresthesia - 2%, P - <1%
  • Dizziness - 2%, P - 1%
  • Drowsiness - 2%, P - <1%
  • Malaise/Fatigue - 2%, P - 1%
  • Throat/neck symptoms - 2%, P - 1%
  • Ergotamines - DO NOT COMBINE. May cause prolonged vasospastic reactions. Do not use within 24 hours of each other.
  • Other 5-HT1 agonists - DO NOT COMBINE. Triptans should not be taken within 24 hours of other 5-HT1 agonists including other triptans.
  • SSRIs/SNRIs - triptans are serotonergic medications, and they may increase the risk of serotonin syndrome when taken with SSRIs and SNRIs
  • Cardiovascular disease - triptans have the potential to cause coronary, cerebral, and peripheral vasospasm. Because of this, they should not be used in patients with known cardiac ischemia, cerebral ischemia (TIA and stroke), or peripheral ischemia (bowel ischemia, intermittent claudication, etc.). Patients at high-risk for having vascular disease (e.g. diabetics, smokers, obese, etc.) should also use caution.
  • Wolff-Parkinson-White syndrome and other accessory pathway conduction disorders - DO NOT USE
  • Prinzmetal's variant angina - DO NOT USE. Triptans may exacerbate vasospastic heart disease.
  • Hemiplegic or basilar migraine - DO NOT USE
  • Chest pain and tightness - triptans may cause a sensation of pain and tightness in the chest, neck, and/or throat. These symptoms are more common with injectable drug forms. In most patients, triptan-induced chest pain is not thought to be caused by ischemia and is generally not serious. [1,4]
  • Cardiac arrhythmias - in a small number of patients, life-threatening arrhythmias have been reported within a few hours of taking triptans
  • Hypertension - triptans may cause a short-term rise in blood pressure. Use caution in patients with uncontrolled hypertension.
  • Raynaud's syndrome - triptans may exacerbate symptoms of Raynaud's syndrome
  • Vision changes - rare cases of vision changes and vision loss have been reported with triptan use
  • Serotonin syndrome - serotonin syndrome has occurred in patients taking triptans. The risk may be higher when taken with other serotonergic medications.
  • Medication overuse headache - overuse of headache medications including triptans (e.g. ≥ 10 days a month) may cause an increase in headache frequency and worsening headache with drug withdrawal.
  • Anaphylactic reactions - cases of anaphylaxis including angioedema have been reported in patients taking triptans
  • Kidney disease
    • CrCl 30 - 90 ml/min - starting dose is 1 mg; do not exceed 2.5 mg over 24 hours
    • CrCl < 15 ml/min - DO NOT USE
  • Liver disease
    • Mild-to-moderate (Child-Pugh A/B) - starting dose is 1 mg; do not exceed 2.5 mg over 24 hours
    • Severe (Child-Pugh C) - DO NOT USE

Drug Dosage form Dosage Generic/Price Other Mechanism of Action/
FDA-approved indications
Side Effects
P = % of patients on placebo
who experienced side effect
Drug Interactions Precautions/
Contraindications
Rizatriptan

(Maxalt®)
(Maxalt-MLT®)
Maxalt® - tablet
  • 5 mg
  • 10 mg

Maxalt-MLT®
Orally disintegrating tablet

  • 5 mg
  • 10 mg
Migraine headache

  • Pediatric 6 - 17 years
    • < 40 kg (88 lbs): 5 mg
    • ≥ 40 kg (88 lbs): 10 mg
    • The efficacy and safety of more than one dose in 24 hours has not been established

  • Adults
    • Initial: 5 - 10 mg
    • May repeat in 2 hours if needed
    • Do not exceed 30 mg in 24 hours

When taken with propranolol

  • Pediatric (6 - 17 years)
    • < 40 kg (88 lbs): DO NOT COMBINE
    • ≥ 40 kg (88 lbs): Do not exceed a single 5 mg dose in 24 hours

  • Adults
    • Initial: 5 mg
    • Do not exceed 15 mg in 24 hours
Maxalt®
YES/$
(9 tablets)

Maxalt-MLT®
YES/$
(9 tablets)
Other
  • May take without regard to food

Maxalt-MLT
  • Administration with liquid is not necessary

  • Dissolves on tongue and is swallowed with saliva

  • Do not remove from blister pack until just prior to dosing

Pharmacokinetics
Maxalt
  • Time to max level: 1 - 1.5 hours
  • Half-life: 2 - 3 hours

Maxalt-MLT
  • Time to max level: 1.7 - 2.2 hours
  • Half-life: 2 - 3 hours
Mechanism of action
  • Triptans are serotonergic agonists that have a high affinity for 5-HT1D and 5-HT1B receptors

  • The mechanism by which they alleviate migraine headaches is not completely understood. Proposed theories include the following:

    • Cranial vasoconstriction
    • Inhibition of vasoactive peptide release
    • Blockade of neurotransmitter release in the dorsal horn
    • Facilitation of descending pain inhibitory systems [1]

FDA-approved indications

  • Acute migraine headache with or without aura in adults and pediatric patients 6 - 17 years old
NOTE: Side effects listed are for the 10 mg dose. Only side effects that occurred at an incidence greater than placebo are listed.

Adults
  • Dizziness - 9%, P - 5%
  • Somnolence - 8%, P - 4%
  • Fatigue - 7%, P - 2%
  • Nausea - 6%, P - 4%
  • Paresthesia - 4%, P - <2%
  • Chest pain - 3%, P - 1%
  • Pain, location unspecified - 3%, P - <2%
  • Dry mouth - 3%, P - 1%
  • Neck/throat/jaw pain - 2%, P - 1%
  • Regional pain - 2%, P - 0%
  • Headache - 2%, P - <1%
  • MAO-A inhibitors and nonselective MAO inhibitors - DO NOT COMBINE or start rizatriptan within 2 weeks of discontinuing an MAO inhibitor. Rizatriptan is metabolized by MAO-A. Selective MAO-A and nonselective MAO inhibitors may increase blood levels. Selective MAO-B inhibitors would not be expected to affect rizatriptan levels.
  • Propranolol - propranolol increases rizatriptan levels. See Dosage for dosing recommendations.
  • Ergotamines - DO NOT COMBINE. May cause prolonged vasospastic reactions. Do not use within 24 hours of each other.
  • Other 5-HT1 agonists - DO NOT COMBINE. Triptans should not be taken within 24 hours of other 5-HT1 agonists including other triptans.
  • SSRIs/SNRIs - triptans are serotonergic medications, and they may increase the risk of serotonin syndrome when taken with SSRIs and SNRIs
  • Cardiovascular disease - triptans have the potential to cause coronary, cerebral, and peripheral vasospasm. Because of this, they should not be used in patients with known cardiac ischemia, cerebral ischemia (TIA and stroke), or peripheral ischemia (bowel ischemia, intermittent claudication, etc.). Patients at high-risk for having vascular disease (e.g. diabetics, smokers, obese, etc.) should also use caution.
  • Wolff-Parkinson-White syndrome and other accessory pathway conduction disorders - DO NOT USE
  • Prinzmetal's variant angina - DO NOT USE. Triptans may exacerbate vasospastic heart disease.
  • Hemiplegic or basilar migraine - DO NOT USE
  • Chest pain and tightness - triptans may cause a sensation of pain and tightness in the chest, neck, and/or throat. These symptoms are more common with injectable drug forms. In most patients, triptan-induced chest pain is not thought to be caused by ischemia and is generally not serious. [1,4]
  • Cardiac arrhythmias - in a small number of patients, life-threatening arrhythmias have been reported within a few hours of taking triptans
  • Hypertension - triptans may cause a short-term rise in blood pressure. Use caution in patients with uncontrolled hypertension.
  • Raynaud's syndrome - triptans may exacerbate symptoms of Raynaud's syndrome
  • Vision changes - rare cases of vision changes and vision loss have been reported with triptan use
  • Serotonin syndrome - serotonin syndrome has occurred in patients taking triptans. The risk may be higher when taken with other serotonergic medications.
  • Medication overuse headache - overuse of headache medications including triptans (e.g. ≥ 10 days a month) may cause an increase in headache frequency and worsening headache with drug withdrawal.
  • Anaphylactic reactions - cases of anaphylaxis including angioedema have been reported in patients taking triptans
  • Phenylketonuria - Maxalt-MLT contains phenylalanine. The 5 and 10 mg orally disintegrating tablets contain 1.1 and 2.1 mg phenylalanine, respectively.
  • Kidney disease
    • CrCl ≥ 10 ml/min: no dose adjustment necessary
  • Liver disease
    • Mild (Child-Pugh A) - no dose adjustment necessary
    • Moderate-severe (Child-Pugh B/C) - clearance is decreased. Use caution.

Drug Dosage form Dosage Generic/Price Other Mechanism of Action/
FDA-approved indications
Side Effects
P = % of patients on placebo
who experienced side effect
Drug Interactions Precautions/
Contraindications
Sumatriptan

(Imitrex®)
(Alsuma®)
(Sumavel®)
(Zecuity®)
(Zembrace®)
(Onzetra®)
Imitrex® - tablet
  • 25 mg
  • 50 mg
  • 100 mg
  • Comes in packs of 9 tablets

Imitrex® - nasal spray
  • 5 mg
  • 20 mg
  • Comes in box with 6 single-dose spray devices

Imitrex® prefilled syringe and vial
  • 6 mg (6 mg/0.5 ml)

Imitrex® statdose injection
  • 4 mg (4 mg/0.5 ml)
  • 6 mg (6 mg/0.5 ml)
  • Comes in pack with 2 cartridges

Alsuma® - injection
  • 6 mg (6 mg/0.5 ml)
  • Comes in pack with 2 autoinjectors

Zembrace® injection
  • 3 mg single use autoinjector
  • Comes in pack with 4 injectors

Sumavel Dosepro® - injection
  • 4 mg (4 mg/0.5 ml)
  • 6 mg (6 mg/0.5 ml)
  • Comes in pack with 6 pens
  • Delivers medication through air injection (no needle)

Onzetra® nasal powder
  • Comes in kit with 8 pouches and 2 delivery systems
  • Each pouch contains 2 nosepieces
  • Each nosepiece contains 11 mg sumatriptan

Zecuity®
Iontophoretic transdermal system

  • Each system delivers 6.5 mg over 4 hours
  • Comes in carton of 4 systems
  • Sales currently suspended

Treximet® - tablet
  • Sumatriptan : naproxen
    • 85 mg : 500 mg
Migraine headache
Imitrex tablet
  • Adults
    • Initial: 25 - 100 mg
    • May repeat in 2 hours if needed
    • Do not exceed 200 mg in 24 hours
    • 50 mg dose may be more effective than 25 mg dose
    • If tablet is given after injection, may give up to 100 mg/day of tablet doses

Imitrex nasal spray
  • Adults
    • Initial: 5, 10, or 20 mg
    • May repeat one time in 2 hours if needed
    • Do not exceed 40 mg in 24 hours
    • If a 10 mg dose is desired, administer a 5 mg dose in each nostril
    • 20 mg dose may be more effective than lower doses

Imitrex/Alsuma/Sumavel injection
  • Adults
    • Initial: 6 mg subcutaneously
    • May repeat in 1 hour if needed
    • Do not exceed 12 mg in 24 hours
    • If side effects are dose limiting, lower doses (1 - 5 mg) may be used.

Zembrace injection
  • Adults
    • Initial: 3 mg subcutaneously
    • May repeat in 1 hour if needed
    • Do not exceed 12 mg in 24 hours

Onzetra nasal powder
  • Adults
    • Initial: 22 mg (2 nosepieces) via delivery device
    • A second dose (22 mg) may be given 2 hours later
    • Do not exceed 44 mg in 24 hours

Zecuity transdermal system
  • Adults
    • Initial: Apply one transdermal system
    • May apply second system after 2 hours if needed
    • Do not apply more than 2 systems in 24 hours
    • Apply to upper arm or thigh. Skin should be relatively hair-free and without scars, tattoos, or abrasions.
    • Do not apply near electrically-active devices (e.g. pacemaker, insulin pump)
    • Do not reuse application site until it is erythema free for 3 days
    • Sales currently suspended - see TEVA notice for more

Treximet
  • Adults
    • Initial: 1 tablet (85/500)
    • May repeat one time in 2 hours if needed
    • Do not exceed 2 tablets in 24 hours

Cluster headache
Imitrex, Alsuma, Sumavel injections
  • Adults
    • Initial: 6 mg subcutaneously
    • May repeat in 1 hour if needed
    • Do not exceed 12 mg in 24 hours
Imitrex tablet
YES/$
(9 tablets)

Imitrex nasal spray
YES/$$$-$$$$
(6 sprays)

Imitrex syringe
YES/$$-$$$
(1 syringe)

Imitrex vial
YES/$
(1 vial)

Imitrex statdose
YES/$$-$$$$
(2 cartridges)

Alsuma
NO/$$$$
(2 injections)

Sumavel
NO/$$$$
(6 injections)

Zembrace
NO/$$$$
(4 injections)

Onzetra
NO/$$$$
(8 pouches)

Zecuity
NO/$$$$
(4 systems)

Treximet
NO/$$$$
(6 tablets)

Other
  • May take without regard to food

Imitrex, Alsuma, Zembrace injections
  • Injection is typically given in the side of the thigh or the upper arm
  • Store at room temperature. Protect from light.

Sumavel injection
  • Injection is delivered by air. There is no needle.
  • Injection is given in the abdomen or thigh. Do not give within 2 inches of the naval. Do not give in arm.
  • Store at room temperature. Protect from light.

Imitrex nasal spray
  • Blow nose before administering
  • Store at room temperature. Protect from light.

Onzetra nasal powder
  • Powder capsule is placed into delivery device
  • Device is placed in nose and mouth. Patient blows through mouthpiece and powder is delivered into nose.
  • Store at room temperature

Zecuity
  • System must be activated by pushing button. Once activated, red light is on while system is delivering drug. Once drug delivery stops, red light turns off.
  • Zecuity contains metal. Do not wear during MRI.

Pharmacokinetics
Imitrex tablet
  • Time to max level: 2 - 2.5 hours
  • Half-life: 2.5 hours

Imitrex, Alsuma, Zembrace injections
  • Time to max level: 12 minutes
  • Half-life: ∼ 2 hours

Sumavel injection
  • Time to max level: 12 minutes
  • Half-life: 102 minutes

Imitrex nasal spray
  • Time to max level: ?
  • Half-life: ∼ 2 hours

Onzetra nasal powder
  • Time to max level: 45 minutes
  • Half-life: 3 hours

Zecuity transdermal
  • Time to max level: 1.1 hours
  • Half-life: 3.1 hours
Mechanism of action
  • Triptans are serotonergic agonists that have a high affinity for 5-HT1D and 5-HT1B receptors

  • The mechanism by which they alleviate migraine headaches is not completely understood. Proposed theories include the following:

    • Cranial vasoconstriction
    • Inhibition of vasoactive peptide release
    • Blockade of neurotransmitter release in the dorsal horn
    • Facilitation of descending pain inhibitory systems [1]

FDA-approved indications

Imitrex tablet and nasal spray/Zembrace/Zecuity/Onzetra
  • Acute migraine headache with or without aura in adults

Imitrex, Alsuma, Sumavel injections
  • Acute migraine headache with or without aura in adults

  • Cluster headache
Tablet
NOTE: Side effects listed are for the 50 mg dose. Only side effects that occurred at an incidence greater than placebo are listed.
  • Paresthesia - 5%, P - 2%
  • Chest pain - 2%, P - 1%
  • Neck/throat/jaw pain - 2%, P - <1%
  • Fatigue - 2%, P - <1%

Injection
NOTE: Side effects listed are from the Imitrex PI (6 mg dose). Only side effects that occurred at an incidence ≥ 3% more than placebo are listed.
  • Injection site reaction - 59%, P - 24%
  • Tingling - 14%, P - 3%
  • Dizziness - 12%, P - 4%
  • Warm/hot sensation - 11%, P - 4%
  • Burning sensation - 7%, P - <1%
  • Heavy feeling - 7%, P - 1%
  • Pressure sensation - 7%, P - 2%
  • Flushing - 7%, P - 2%
  • Weakness - 5%, P - <1%
  • Neck pain stiffness - 5%, P - <1%
  • Feeling of tightness - 5%, P - <1%
  • Numbness - 5%, P - 2%
  • Chest discomfort - 5%, P - 1%
  • Chest tightness - 3%, P - <1%
  • Throat discomfort - 3%, P - <1%

Nasal spray
NOTE: Side effects listed are for the 20 mg dose. Only side effects that occurred at an incidence ≥ 1% more than placebo are listed.
  • Bad/unusual taste - 24.5%, P - 1.7%
  • Nausea/vomiting - 13.5%, P - 11.3%
  • Nasal discomfort - 3.8%, P - 2.4%
  • Throat discomfort - 2.4%, P - 0.9%
  • Burning sensation - 1.4%, P - 0.1%

Onzetra nasal powder
  • Abnormal taste - 20%, P - 3%
  • Nasal discomfort - 11%, P - 1%
  • Rhinorrhea - 5%, P - 2%
  • Rhinitis - 2%, P - 0%

Zecuity transdermal system
  • Application site redness - up to 55% of patients
  • Application site pain - 26%
  • Application site paresthesia - 9%
  • Application site pruritus - 8%
  • Application site warmth - 6%
  • Application site discomfort - 6%
  • Application site irritation - 4%
  • Application site discoloration - 3%
  • MAO-A inhibitors and nonselective MAO inhibitors - DO NOT COMBINE or start sumatriptan within 2 weeks of discontinuing an MAO inhibitor. Sumatriptan is metabolized by MAO-A. Selective MAO-A and nonselective MAO inhibitors may increase blood levels.
  • Ergotamines - DO NOT COMBINE. May cause prolonged vasospastic reactions. Do not use within 24 hours of each other.
  • Other 5-HT1 agonists - DO NOT COMBINE. Triptans should not be taken within 24 hours of other 5-HT1 agonists including other triptans.
  • SSRIs/SNRIs - triptans are serotonergic medications, and they may increase the risk of serotonin syndrome when taken with SSRIs and SNRIs
  • Cardiovascular disease - triptans have the potential to cause coronary, cerebral, and peripheral vasospasm. Because of this, they should not be used in patients with known cardiac ischemia, cerebral ischemia (TIA and stroke), or peripheral ischemia (bowel ischemia, intermittent claudication, etc.). Patients at high-risk for having vascular disease (e.g. diabetics, smokers, obese, etc.) should also use caution.
  • Wolff-Parkinson-White syndrome and other accessory pathway conduction disorders - DO NOT USE
  • Prinzmetal's variant angina - DO NOT USE. Triptans may exacerbate vasospastic heart disease.
  • Hemiplegic or basilar migraine - DO NOT USE
  • Chest pain and tightness - triptans may cause a sensation of pain and tightness in the chest, neck, and/or throat. These symptoms are more common with injectable drug forms. In most patients, triptan-induced chest pain is not thought to be caused by ischemia and is generally not serious. [1,4]
  • Cardiac arrhythmias - in a small number of patients, life-threatening arrhythmias have been reported within a few hours of taking triptans
  • Hypertension - triptans may cause a short-term rise in blood pressure. Use caution in patients with uncontrolled hypertension.
  • Raynaud's syndrome - triptans may exacerbate symptoms of Raynaud's syndrome
  • Vision changes - rare cases of vision changes and vision loss have been reported with triptan use
  • Serotonin syndrome - serotonin syndrome has occurred in patients taking triptans. The risk may be higher when taken with other serotonergic medications.
  • Medication overuse headache - overuse of headache medications including triptans (e.g. ≥ 10 days a month) may cause an increase in headache frequency and worsening headache with drug withdrawal.
  • Anaphylactic reactions - cases of anaphylaxis including angioedema have been reported in patients taking triptans
  • Local irritation (nasal spray) - in trials, symptoms such as burning, numbness, paresthesia, discharge, and pain or soreness were reported in about 5% of patients. Symptoms typically resolved after 2 hours. The long-term effects of imitrex nasal spray on the nose and throat have not been evaluated.
  • Allergic contact dermatitis (Zecuity) - in trials, 4% of Zecuity patients developed allergic contact dermatitis (ACD) after 1 year of use. ACD is marked by plaques, vesicles, pruritus, and bullous eruptions. Erythema is common and not necessarily a sign of ACD. Patients who develop ACD should stop using Zecuity. These patients are also at risk of developing systemic reactions to other forms of sumatriptan (e.g. oral, nasal, injection).
  • Seizures - in rare cases, patients have experienced seizures after taking sumatriptan. Use caution in susceptible patients.
  • Corneal opacities - in dogs, sumatriptan has been shown to cause corneal opacities and other defects. It is unknown if similar effects occur in humans.
  • Kidney disease - has not been studied. Use caution.
  • Liver disease
    • Mild to moderate (Child-Pugh A/B) - maximum single dose is 50 mg
    • Severe (Child-Pugh C) - DO NOT USE

Drug Dosage form Dosage Generic/Price Other Mechanism of Action/
FDA-approved indications
Side Effects
P = % of patients on placebo
who experienced side effect
Drug Interactions Precautions/
Contraindications
Zolmitriptan

(Zomig®)
(Zomig-ZMT®)
Zomig® - tablet
  • 2.5 mg
  • 5 mg
  • Comes in pack of 6 tablets for 2.5 mg dose and 3 tablets for 5 mg dose

Zomig-ZMT®
Orally disintegrating tablet

  • 2.5 mg
  • 5 mg
  • Comes in pack of 6 tablets for 2.5 mg dose and 3 tablets for 5 mg dose

Zomig® - nasal spray
  • 2.5 mg
  • 5 mg
  • Comes in box with 6 single-dose spray devices
Migraine headache

Zomig/Zomig-ZMT tablet
  • Adults
    • Initial: 2.5 - 5 mg
    • May repeat in 2 hours if needed
    • Do not exceed 10 mg in 24 hours
    • 2.5 mg tablet may be broken in half for a lower dose. Do not half oral disintegrating tablet.
    • In studies, 5 mg dose offered little benefit over 2.5 mg dose

Zomig nasal spray
  • Adults
    • Initial: 2.5 mg intranasally
    • May repeat in 2 hours if needed
    • Dose of 5 mg may be used in some patients
    • Do not exceed 10 mg in 24 hours
Zomig®
YES/$
(3X5mg tablets)

Zomig-ZMT®
YES/$
(3X5mg tablets)

Zomig nasal spray
NO/$$$$
(6 doses)

Other

Zomig
  • May take without regard to food
  • 2.5 mg tablet is scored so it may be broken in half

Zomig-ZMT
  • Administration with liquid is not necessary
  • Dissolves on tongue and is swallowed with saliva
  • Do not remove from blister pack until just prior to dosing
  • Do not break in half

Nasal spray
  • Blow nose before use
  • Store at room temperature

Pharmacokinetics

Zomig tablet
  • Time to max level: 1.5 hours
  • Half-life: 3 hours

Zomig-ZMT
  • Time to max level: 3 hours
  • Half-life: 3 hours

Zomig nasal spray
  • Time to max level: 3 hours
  • Half-life: 3 hours
Mechanism of action
  • Triptans are serotonergic agonists that have a high affinity for 5-HT1D and 5-HT1B receptors

  • The mechanism by which they alleviate migraine headaches is not completely understood. Proposed theories include the following:

    • Cranial vasoconstriction
    • Inhibition of vasoactive peptide release
    • Blockade of neurotransmitter release in the dorsal horn
    • Facilitation of descending pain inhibitory systems [1]

FDA-approved indications

  • Acute migraine headache with or without aura in adults
NOTE: Side effects listed are for the 2.5 mg dose. Only side effects that occurred at an incidence ≥ 2% more than placebo are listed.

  • Nausea - 9%, P - 4%
  • Dizziness - 8%, P - 4%
  • Paresthesia - 7%, P - 2%
  • Neck/throat/jaw pain - 7%, P - 3%
  • Somnolence - 6%, P - 3%
  • Chest pain - 3%, P - 1%
  • Other pressure/tightness/heaviness - 2%, P - 0%
  • MAO-A inhibitors and nonselective MAO inhibitors - DO NOT COMBINE or start zolmitriptan within 2 weeks of discontinuing an MAO inhibitor. Zolmitriptan is metabolized by MAO-A. Selective MAO-A and nonselective MAO inhibitors may increase blood levels. Selective MAO-B inhibitors would not be expected to affect zolmitriptan levels.
  • Ergotamines - DO NOT COMBINE. May cause prolonged vasospastic reactions. Do not use within 24 hours of each other.
  • Other 5-HT1 agonists - DO NOT COMBINE. Triptans should not be taken within 24 hours of other 5-HT1 agonists including other triptans.
  • Cimetidine - cimetidine has been shown to double the half-life and AUC of zolmitriptan
  • SSRIs/SNRIs - triptans are serotonergic medications, and they may increase the risk of serotonin syndrome when taken with SSRIs and SNRIs
  • Cardiovascular disease - triptans have the potential to cause coronary, cerebral, and peripheral vasospasm. Because of this, they should not be used in patients with known cardiac ischemia, cerebral ischemia (TIA and stroke), or peripheral ischemia (bowel ischemia, intermittent claudication, etc.). Patients at high-risk for having vascular disease (e.g. diabetics, smokers, obese, etc.) should also use caution.
  • Wolff-Parkinson-White syndrome and other accessory pathway conduction disorders - DO NOT USE
  • Prinzmetal's variant angina - DO NOT USE. Triptans may exacerbate vasospastic heart disease.
  • Hemiplegic or basilar migraine - DO NOT USE
  • Chest pain and tightness - triptans may cause a sensation of pain and tightness in the chest, neck, and/or throat. These symptoms are more common with injectable drug forms. In most patients, triptan-induced chest pain is not thought to be caused by ischemia and is generally not serious. [1,4]
  • Cardiac arrhythmias - in a small number of patients, life-threatening arrhythmias have been reported within a few hours of taking triptans
  • Hypertension - triptans may cause a short-term rise in blood pressure. Use caution in patients with uncontrolled hypertension.
  • Raynaud's syndrome - triptans may exacerbate symptoms of Raynaud's syndrome
  • Vision changes - rare cases of vision changes and vision loss have been reported with triptan use
  • Serotonin syndrome - serotonin syndrome has occurred in patients taking triptans. The risk may be higher when taken with other serotonergic medications.
  • Medication overuse headache - overuse of headache medications including triptans (e.g. ≥ 10 days a month) may cause an increase in headache frequency and worsening headache with drug withdrawal.
  • Anaphylactic reactions - cases of anaphylaxis including angioedema have been reported in patients taking triptans
  • Ophthalmic effects - in rat studies, zolmitriptan at very high doses was found to bind to melanin in the retina. The significance of this in humans is unknown.
  • Phenylketonuria - Zomig-ZMT contains phenylalanine. The 2.5 mg and 5 mg tablets contain 2.81 mg and 5.62 mg of phenylalanine respectively.
  • Kidney disease
    • CrCl ≥ 26 ml/min: no dose adjustment necessary
    • CrCl 5 - 25 ml/min: clearance is reduced by 25%. Use caution.
  • Liver disease
    • Moderate-severe (Child-Pugh B/C) - clearance is decreased. Severe blood pressure elevations may occur. Use doses < 2.5 mg or avoid use.




Drug Dosage form Dosage Generic/Price Other Mechanism of Action/
FDA-approved indications
Side Effects Drug Interactions Precautions/
Contraindications
Ergotamine
tartrate

(Cafergot®)
(Migergot®)
Cafergot® - tablet
  • Ergotamine : caffeine
    • 1 mg : 100 mg

Migergot® - suppository
  • Ergotamine : caffeine
    • 2 mg : 100 mg
    • Comes in boxes of 12 suppositories
Migraine headache

Cafergot
  • Adults
    • Initial: 2 tablets with first sign of headache
    • May take 1 additional tablet every 30 minutes if needed
    • Do not exceed 6 tablets
    • Total weekly dose should not exceed 10 tablets

Migergot
  • Adults
    • Initial: one suppository at start of headache
    • May repeat one time in 1 hour if needed
    • Do not exceed 2 suppositories
    • Total weekly dose should not exceed 5 suppositories
Cafergot®
YES/$$$$
(30 tablets)

Migergot®
NO/$$$$
(12 suppositories)

Other
Cafergot
  • May take without regard to food

Migergot
  • Store in refrigerator

Pharmacokinetics

Cafergot/Migergot
  • Time to max level: ?
  • Half-life: 2 hours [5]
Mechanism of action
  • Ergotamine is a serotonergic agonist that has a high affinity for 5-HT1B/1D receptors. It also binds dopamine and noradrenaline receptors. [5]

  • The mechanism by which ergotamine alleviates migraine headaches is not completely understood. Proposed theories include the following:

    • Cranial vasoconstriction
    • Inhibition of vasoactive peptide release
    • Blockade of neurotransmitter release in the dorsal horn
    • Facilitation of descending pain inhibitory systems [1]

FDA-approved indications

Cafergot/Migergot
  • Migraine headache in adults

NOTE: Incidence of side effects with ergotamine are not well-defined

  • Paraesthesia
  • Nausea and vomiting
  • Numbness
  • Weakness
  • Vertigo
  • Edema
  • Itching
  • Anal ulcer (suppository)
  • CYP3A4 inhibitors - DO NOT COMBINE with strong CYP3A4 inhibitors. Ergotamine is a sensitive CYP3A4 substrate. Life-threatening peripheral ischemia has been reported with combined use. Use caution with mild to moderate CYP3A4 inhibitors.
  • Vasoconstrictors - DO NOT COMBINE. May cause elevated blood pressure.
  • Other 5HT1 agonists (ex. triptans) - DO NOT COMBINE. May cause prolonged vasospastic reactions. Do not use within 24 hours of each other.
  • Propranolol - propranolol may potentiate the vasoconstrictive properties of ergotamines
  • Nicotine - nicotine may potentiate the vasoconstrictive properties of ergotamines
  • SSRIs/SNRIs - ergotamine is a serotonergic medication, and it may increase the risk of serotonin syndrome when taken with SSRIs and SNRIs
  • Cardiovascular disease - ergotamines have the potential to cause coronary, cerebral, and peripheral vasospasm. Because of this, they should not be used in patients with known cardiac ischemia, cerebral ischemia (TIA and stroke), or peripheral ischemia (bowel ischemia, intermittent claudication, etc.). Patients at high-risk for having vascular disease (e.g. diabetics, smokers, obese, etc.) should also use caution.
  • Prinzmetal's variant angina - DO NOT USE. Ergotamines may exacerbate vasospastic heart disease.
  • Pregnancy and nursing - DO NOT USE. Ergotamines may cause fetal harm, and they possesses oxytocic properties. Ergotamines may inhibit prolactin and suppress lactation.
  • Hemiplegic or basilar migraine - DO NOT USE
  • Fibrosis - there have been case reports of pleural, retroperitoneal, and cardiac valvular fibrosis following long-term use of ergotamines
  • Hypertension - ergotamines may cause a rise in blood pressure. Use caution in patients with uncontrolled hypertension.
  • Raynaud's syndrome - ergotamines may exacerbate symptoms of Raynaud's syndrome
  • Serotonin syndrome - serotonin syndrome has occurred in patients taking ergotamines. The risk may be higher when taken with other serotonergic medications.
  • Medication overuse headache - overuse of headache medications including ergotamines (e.g. ≥ 10 days a month) may cause an increase in headache frequency and worsening headache with drug withdrawal.
  • Kidney disease - has not been studied. Do not use in severe kidney disease (CrCl < 30 ml/min).
  • Liver disease - has not been studied. Do not use in severe liver disease (Child-Pugh C)


Drug Dosage form Dosage Generic/Price Other Mechanism of Action/
FDA-approved indications
Side Effects
P = % of patients on placebo
who experienced side effect
Drug Interactions Precautions/
Contraindications
Dihydroergotamine
mesylate

(D.H.E. 45®)
(Migranal®)
D.H.E. 45® - injection
  • 1 mg (1 mg/ml)
  • Comes in single dose vials and ampules
  • Comes in packs of 10 vials/ampules

Migranal® - nasal spray
  • 4 mg
  • Comes in vial that is attached to spray device
  • Comes in pack of 8 vials
Migraine headache

D.H.E. 45 injection
  • Adults
    • Initial: 1 mg given intramuscularly or subcutaneously
    • May repeat in 1 hour if needed
    • Do not exceed 3 mg in 24 hours
    • Total weekly dose should not exceed 6 mg

Migranal nasal spray
  • Adults
    • One spray (0.5mg) in each nostril. Fifteen minutes later, an additional spray should be administered in each nostril (total dose of 2 mg).
    • No benefit of doses greater than 2 mg has been demonstrated
    • The safety of doses greater than 3 mg in 24 hours has not been evaluated

Cluster headache

D.H.E. 45 injection
  • Adults
    • Initial: 1 mg given intramuscularly or subcutaneously
    • May repeat in 1 hour if needed
    • Do not exceed 3 mg in 24 hours
    • Total weekly dose should not exceed 6 mg
D.H.E. 45®
YES/$$$$
(10 doses)

Migranal®
NO/$$$$
(8 doses)

Other
D.H.E. 45
  • For subcutaneous injection, inject in the middle of the thigh
  • Store below 25°C (77°F), in light-resistant containers
  • Do not refrigerate or freeze
  • Solution should be clear and colorless

Migranal
  • Sprayer must be primed 4 times prior to administration
  • Once sprayer is assembled, drug is good for 8 hours
  • Store below 25°C (77°F). Do not refrigerate or freeze.

Pharmacokinetics

D.H.E. 45 injection
  • Time to max level: ?
  • Half-life: 9 hours

Migranal
  • Time to max level: ?
  • Half-life: 10 hours
Mechanism of action
  • Dihydroergotamine is a serotonergic agonist that has a high affinity for 5-HT1D receptors. It also binds with high affinity to 5-HT1A, 5-HT2A, 5-HT2C, noradrenaline α2A, α2B α1, and dopamine D2L and D3 receptors.

  • The mechanism by which dihydroergotamine alleviates migraine headaches is not completely understood. Proposed theories include the following:

    • Cranial vasoconstriction
    • Inhibition of vasoactive peptide release
    • Blockade of neurotransmitter release in the dorsal horn
    • Facilitation of descending pain inhibitory systems [1]

FDA-approved indications

D.H.E. 45
  • Acute migraine headache with or without aura in adults
  • Cluster headache

Migranal
  • Acute migraine headache with or without aura in adults

D.H.E. 45
NOTE: Incidence of side effects with D.H.E. 45 are not well-defined

  • Paraesthesia
  • Dizziness
  • Anxiety
  • Shortness of breath
  • Headache
  • Flushing
  • Diarrhea
  • Rash
  • Increased sweating

Migranal
NOTE: Only side effects that occurred at an incidence of ≥ 2% more than placebo are listed

  • Runny nose - 26%, P - 7%
  • Nausea - 10%, P - 4%
  • Altered sense of taste - 8%, P - 1%
  • Application site reaction - 6%, P - 2%
  • Dizziness - 4%, P - 2%
  • Vomiting - 4%, P - 1%
  • Pharyngitis - 3%, P - 1%
  • Diarrhea - 2%, P - <1%
  • CYP3A4 inhibitors - DO NOT COMBINE with strong CYP3A4 inhibitors. Dihydroergotamine is a sensitive CYP3A4 substrate. Life-threatening peripheral ischemia has been reported with combined use. Use caution with mild to moderate CYP3A4 inhibitors.
  • Vasoconstrictors - DO NOT COMBINE. May cause elevated blood pressure.
  • Other 5HT1 agonists (ex. triptans) - DO NOT COMBINE. May cause prolonged vasospastic reactions. Do not use within 24 hours of each other.
  • Propranolol - propranolol may potentiate the vasoconstrictive properties of ergotamines
  • Nicotine - nicotine may potentiate the vasoconstrictive properties of ergotamines
  • SSRIs/SNRIs - dihydroergotamine is a serotonergic medication, and it may increase the risk of serotonin syndrome when taken with SSRIs and SNRIs
  • Cardiovascular disease - ergotamines have the potential to cause coronary, cerebral, and peripheral vasospasm. Because of this, they should not be used in patients with known cardiac ischemia, cerebral ischemia (TIA and stroke), or peripheral ischemia (bowel ischemia, intermittent claudication, etc.). Patients at high-risk for having vascular disease (e.g. diabetics, smokers, obese, etc.) should also use caution.
  • Prinzmetal's variant angina - DO NOT USE. Ergotamines may exacerbate vasospastic heart disease.
  • Pregnancy and nursing - DO NOT USE. Ergotamines may cause fetal harm, and they possesses oxytocic properties. Ergotamines may inhibit prolactin and suppress lactation.
  • Hemiplegic or basilar migraine - DO NOT USE
  • Fibrosis - there have been case reports of pleural, retroperitoneal, and cardiac valvular fibrosis following prolonged daily use of injectable dihydroergotamine mesylate
  • Hypertension - ergotamines may cause a rise in blood pressure. Use caution in patients with uncontrolled hypertension.
  • Raynaud's syndrome - ergotamines may exacerbate symptoms of Raynaud's syndrome
  • Serotonin syndrome - serotonin syndrome has occurred in patients taking ergotamines. The risk may be higher when taken with other serotonergic medications.
  • Medication overuse headache - overuse of headache medications including ergotamines (e.g. ≥ 10 days a month) may cause an increase in headache frequency and worsening headache with drug withdrawal.
  • Kidney disease - has not been studied. Do not use in severe kidney disease (CrCl < 30 ml/min).
  • Liver disease - has not been studied. Do not use in severe liver disease (Child-Pugh C)



  • PRICING

    • $ = 0 - $50
    • $$ = $51 - $100
    • $$$ = $101 - $150
    • $$$$ = > $151

    • Pricing based on one month of therapy at standard dosing in an adult
    • Pricing based on survey of GoodRX.com®, HEB®, and Costco®, [accessed 8/2015]
    • Pricing may vary by region and availability


  • References:

    • Manufacturer's package insert