Dr. Messoud Ashina of the Danish Headache Center led a group of European researchers in analyzing the efficacy of migraine medications for treating acute migraine attacks. Their paper published in the British Medical Journal, “Comparative effects of drug interventions for the acute management of migraine episodes in adults: systematic review and network meta-analysis”, looked at 137 randomised controlled trials comprising 89,445 participants allocated to one of 17 active interventions or placebo.
They concluded that “Overall, eletriptan, rizatriptan, sumatriptan, and zolmitriptan had the best profiles, and they were more efficacious than the recently marketed drugs lasmiditan, rimegepant, and ubrogepant.”
When I decided to specialize in treating headaches in 1987, the options for the treatment of acute migraine attacks were very limited. We had NSAIDs, like aspirin and ibuprofen, opioids (narcotics), and ergotamines. Now, we have a cornucopia of options – seven triptans (the first in this group, sumatriptan, was introduced in 1992), three gepants, and one ditan.
Triptans work on serotonin receptors, gepants affect CGRP, and ditan, lasmiditan (Reyvow) works on a different serotonin receptor than triptans.
Over more than 30 years, triptans have proven to be exceptionally safe and effective. In many countries, they are sold without a prescription. Since patents for these drugs have mostly expired, they have become inexpensive.
Gepants were introduced almost five years ago. Ubrogepant(Ubrelvy) and rimegepant (Nurtec) came out first, and more recently, a nasal spray of zavegepant (Zavzpret) was added to this group. They also appear effective and safe, although they have not withstood the test of time like the triptans. And, because they are still protected by patents, they are costly. I don’t think that the prices are too high – if companies cannot recoup literally billions of dollars it takes to get FDA approval, no new drugs will emerge.
It is good to have all these options available because triptans do not work for about 30-40% of patients. For these people, gepants can be life-saving.
In the US, many insurers insist that a patient tries one or two triptans first before they will agree to pay for the more expensive gepants.
In the analysis, eletriptan came out first. However, even though a generic version was introduced in 2017, the cost has not come down as much as for sumatriptan or rizatriptan. Generic sumatriptan can be bought for $.60 a pill, while eletriptan costs $2 a pill. Another important point is that, despite low cost, insurance companies will cover 6 to 12 tablets a month. Some patients don’t realize that if they need more than this amount each month, they could buy extra by paying out-of-pocket, provided their doctor gives them a prescription for a higher amount.
In the US, eletriptan is available in 20 mg and 40 mg strengths. In some European countries, they come in 80 mg strength. The point is that taking two 40 mg tablets at once is not dangerous.
Some patients report that generics do not work as well as branded drugs. Others find that generics made by different manufacturers differ in their efficacy. The manufacturer’s name is always listed on the pill bottle dispensed by the pharmacy. The reason for this discrepancy is not necessarily due to different amounts of the active drug but rather due to inactive ingredients that hold the pill together. Some may not dissolve as fast or as completely as others. This is another reason why taking a higher-than-recommended dose may be necessary.
Triptans are safer than most over-the-counter drugs, such as ibuprofen (Advil), naproxen (Aleve), or Excedrin. They are safer for your stomach, kidneys, and heart.
