A small number of my patients take triptan medications daily. Many doctors, including neurologists and headache specialists think that taking these drugs daily makes headaches worse, resulting in rebound, or medication overuse headaches (MOH). However, there is no evidence to support this view. Sumatriptan (Imitrex, Treximet), rizatriptan (Maxalt), zolmitriptan (Zomig), naratriptan (Amerge), eletriptan (Relpax), almotriptan (Axert), and frovatriptan (Frova) have revolutionized the treatment of migraines. I started my career in 1986, five years before the introduction of sumatriptan when treatment options were limited to ergots with and without caffeine (Cafergot), barbiturates with caffeine and acetaminophen (Fioricet), and narcotic or opioid drugs (codeine, Vicodin, Percocet). These drugs were not only ineffective for many migraine sufferers, but they also made headaches worse. Dr. Richard Lipton and his colleagues followed over 8,000 patients with migraine headaches for one year. Results of their study showed that taking barbiturates (Fioricet, Fiorinal) and narcotic pain killers increased the risk of migraines become more frequent and even daily and resulting in chronic migraines. We know from many other studies that withdrawal from caffeine and narcotics can result in headaches. However, taking triptans and non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin (Migralex), naproxen (Aleve), ibuprofen (Advil, Motrin) does not lead to worsening of headaches. Only those patients who were taking NSAIDs very frequently to begin with were more likely to develop even more frequent headaches at the end of the year. Aspirin, in fact, was found to have preventive properties – if you were taking aspirin for your migraines at the beginning of the year you were less likely to have worsening of your headaches by the end of the year.
There are also studies showing that NSAIDs taken daily can be effective for the prophylactic (preventive) treatment of migraine headaches. Unfortunately, no studies have been done to show that taking triptans daily can also prevent headaches.
Over the years, I have treated dozens patients with daily triptans. Prescribing sumatriptan or another triptan for daily use was never my original intent. However, most of these patients failed multiple preventive medications, Botox injections, various supplements, biofeedback and acupuncture. Because of the widespread belief that triptans cause rebound headaches most of them tried to stop taking these drugs. After a week or even several weeks, their headaches did not improve, as should be the case with rebound or MOH. In fact, most of them became unable to function and I would resume prescribing 30 and up to 60 tablets of a triptan each month. Sometimes I would prescribe 6 of one, 9 of another, and 18 tablets of the third triptan, depending on what the insurance company would allow. For some patients all triptans work equally well, for some several do, and for others only one out of seven would provide good relief without causing side effects.
The cost of these drugs, even after sumatriptan going generic, has been very high and is now the main obstacle for most patients. The original main concern we had early after the introduction of triptans was the potential serious side effects. But now, 20 years of experience strongly suggests that taking triptans daily does not cause any serious long-term side effects. I do not suggest that they cannot or do not cause serious side effects – they can and do and are contraindicated in patients with coronary artery disease and strokes, but in healthy people they are very safe. For the past several years, triptans have been available in Europe without a prescription.
In conclusion, daily triptans can be a highly effective and safe treatment for a small group of patients with chronic migraine headaches. They should not be prescribed for the prevention of migraines or for daily abortive use, unless other options (excluding barbiturate, caffeine, or narcotics) have been tried.
