Beyond Pills: Nasal sprays and injections for rapid relief in intense migraines

The fundamental point when evaluating treatments with triptans is the characteristics of the migraine attacks. The doctor must know the duration of the attacks, the intensity since the beginning, the presence of recurrences, early or late onset nausea or vomiting, if the attacks occur during the day or at night, and the number of migraine crises per week.¹

Rizatriptan and zolmitriptan have significant nausea improvement versus sumatriptan and naratriptan. In prolongated mild or moderate attacks frovatriptan and naratriptan are good options. In intense attacks since the beginning nasal spray formulation or subcutaneous injections are better options. If the patient suffers recurrence, NSAID can be added to the triptan, or switch to eletriptan or frovatriptan. Orally disintegrating tablets can be helpful in patients with mild nausea. For patients experiencing early onset nausea and vomiting, non-oral options such as intranasal zolmitriptan or sumatriptan are more effective. When the attack awakes the patient, a fast-acting dosage is needed, and intranasal spray or subcutaneous injections are more effective.¹ If there is a lack of efficacy or side effects, we can switch to different triptans, increase the dosage, or combine triptans with NSAIDs.²

Patient education is essential for a successful migraine management plan. It is essential to educate patients about migraine triggers, including stress, skipped meals, disrupted sleep, alcohol, certain types of foods, and menstruation. Keeping a migraine diary may help identify patient-specific triggers. Setting realistic expectations and goals of therapy with the patient is essential, especially since migraine triggers may not always be avoidable.³ On the other hand, we have to prevent medication overuse and, if the patient is taking more than 2-3 triptans per week, they have to consult their GP or specialist.⁴
In the anamnesis it is essential to know that triptans are contraindicated in patients with uncontrolled hypertension, coronary or vascular disease, or stroke. Therefore, the importance of assessing a patients’ personal history of cardiovascular or cerebrovascular disease is vital.¹

Table 1. Triptan, dosage and doses¹
[Caution: Please check the dosage in the label of the respective triptan in your country] The following table 1 provides an overview of triptans and their dosage.

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