Acute Treatment of Episodic Migraine in a Patient No Longer Responding to His Triptan

A 21-year-old college student has had migraine since he was 14 years old. He takes rizatriptan 5 mg as needed for headache, which was effective until approximately 3 years ago, when he began noticing that his response to treatment was inconsistent. At times, acute treatment with rizatriptan was completely ineffective, resulting in attacks that impaired his ability to attend class or study for 1 to 2 days. He continues to tolerate the medication well, but worries that he has become “immune” to rizatriptan.

The patient’s history is taken and an examination is performed.

A review of his previous history reveals that he has been experiencing recurrent headache since he was 12 years old. It was not until he was 14 years old that he was diagnosed with migraine by his pediatrician and started on rizatriptan for acute migraine treatment.

During his attacks, he experiences bilateral, severe, aching head pain accompanied by sensitivity to light and noise. The pain builds over several hours, lasts up to 2 days if untreated, and is worsened with activity. His attacks are not associated with nausea or vomiting, but he does report avoiding food and drink during a migraine. Drinking alcohol or eating food with monosodium glutamate will sometimes precipitate a migraine. Attacks occur once or twice per month and are not associated with aura.

The patient has had success with using rizatriptan until recently. He normally takes a 5-mg dose only when his pain intensity becomes severe, but his headaches have become less responsive to acute treatment over the last 3 years. If he is unable to obtain relief, he tries to lie down for several hours to “sleep it off.”

There have been no significant changes to the patient’s health history, and the characteristics of his migraine attacks remain essentially unchanged. The patient has no other medical problems and takes no other medication. The patient’s remaining review of systems is negative. His vital signs and general, musculoskeletal, and neurologic examinations are normal.

It is important to note that this patient has been treating his attacks with the same dose of rizatriptan that was prescribed to him in adolescence. Additionally, it was discovered that he typically delays treatment until his headache is severe. He also does not take a second dose of rizatriptan if his headache is partially or completely unresponsive to the initial dose.

Because the patient does not experience nausea or vomiting with his attacks, he does not suffer from migraine-related gastroparesis. Thus, his poor responsiveness to rizatriptan is not related to problems with administration and absorption of an oral medication, which can occur with gastroparesis.

In addition, because his headache pain builds over several hours, his attacks are relatively slow in their progression. Changing the route of administration in order to achieve more rapid headache relief can be considered, but is not absolutely necessary at this visit.

Evidence for Alternate Routes of Triptan Administration

Changing the route of triptan administration from oral to parenteral may be considered in order to achieve faster onset of action, since acute headache treatment is most effective if therapy is initiated while the pain is still mild, or to bypass the gastrointestinal tract in patients with nausea or vomiting. Sumatriptan may be administered via the subcutaneous and nasal routes (powder or liquid spray), and zolmitriptan is available as a liquid nasal spray