Effects of Triptans on Migraine Nausea

On Our Forum "I continue to take the triptans after the 1st day. I use them because even IF they don't kill the pain... they at least reduce the nausea (also I use Phenergan or Comapazine for the nausea) and sensitivity to light. If I knew they didn't work...I probably would not take them. For me, if I can keep the nausea at bay... I can function at about a 8 or 9 level of pain.. not functional well, but at least "function". I too, Push the 72hr rule (and I have heard from DR Mama Teri about it!)...But I am very careful!... I learning to say "HELP"!" Join the discussion     Related Resources • Triptans: for Migraine, Cluster, & Menstrual Migraine • Amerge to Prevent Menstrual Migraine • Zomig: A New Dissolving Tablet & More To Come! • Anatomy of a Migraine    Elsewhere on the Web • Imitrex • Maxalt • Zomig • ACHE: The American Council for Headache Education • MAGNUM: The National Migraine Association    Free Newsletter Email Address Subscribe to: BEATING HEADACHES Email Newsletter

In the September, 2001, issue of "Headache: The Journal of Head and Face Pain," researchers published an article that compared Imitrex, Zomig, Maxalt, and Amerge for relief of Migraine nausea symptoms. The study was conducted by Richard B. Lipton, Julio Pascual, Peter J. Goadsby, Helene Massiou, Kathleen A. McCarroll, Kristel Vandormael, Kaihong Jiang, and Christopher R. Lines.

The objective of the study was:

"To compare the effects of oral rizatriptan (Maxalt), sumatriptan (Imitrex), naratriptan (Amerge), and zolmitriptan (Zomig) on the relief and emergence of nausea during a migraine attack."¹

Data was collected from five randomized, placebo-controlled, double-blind clinical trials in which oral Maxalt (rizatriptan) 10 mg was directly compared with oral Imitrex (sumatriptan) 100 mg, 50 mg, 25 mg; Amerge (naratriptan); or Zomig (zolmitriptan) 2.5 mg were compared in use during acute Migraine attack. Migraine was diagnosed according to International Headache Society criteria. Presence or absence of nausea was recorded at baseline and at 0.5, 1, 1.5, and 2 hours after dosing.

Approximately 60% of the participants experienced nausea at baseline.

• Maxalt 10 mg, Imitrex 100 mg, Amerge 2.5 mg, and Zomig 2.5 mg effectively relieved nausea at two hours compared with placebo.
• Sumatriptan 25 mg and 50 mg demonstrated only nonsignificant advantages over placebo.
• Maxalt 10 mg was significantly superior to the placebo.
• Averaged over the 0.5 to 2.0 hours studied, Maxalt 10 mg and Zomig 2.5 mg were superior to the placebo for nausea relief. Amerge 2.5 mg and Imitrex 25, 50, and 100 mg were not. The findings regarding Amerge and Imitrex may be impacted by having included time points before these medications produced benefits.
• Maxalt 10 mg was reported to be significantly more effective than any dosage levels of Zomig and Imitrex as regards the level of nausea at two hours.
• Results with Amerge 10 mg and Zomig 2.5 mg did not differ significantly over the period of 0.5 to two hours or at the two-hour time point.
• "From a clinical perspective, these results suggest that rizatriptan or zolmitriptan may be better choices than sumatriptan or naratriptan for treating patients whose migraine headache is accompanied by prominent nausea."¹

Some conclusions from the study as to why some triptans are more effective for the relief of Migraine nausea symptoms:

• Nausea may be partly attributed as a response to pain. In this case, the triptans that more effectively relieve pain should also more effectively relieve nausea.
  • "This appears to be the case for triptans; within 2 hours after dosing, rizatriptan (Maxalt) 10 mg is generally more effective than other triptans at relieving migraine headache, while zolmitriptan (Zomig) 2.5 mg and the two highest doses of sumatriptan (Imitrex) are more effective than either sumatriptan (Imitrex) 25 mg or naratriptan (Amerge) 2.5 mg.12 Also, patients on rizatriptan (Maxalt) 10 mg who were free of pain at 2 hours were more likely to be free of nausea (92%) than those with mild pain at 2 hours (71%) or moderate to severe pain at 2 hours."1
• Pharmacological differences among the triptans may also be a key.
• It is possible that the differences in 5-HT1 receptor subtype binding profiles may be responsible.

The authors urge caution in interpreting the findings of this study:

"This was a post hoc analysis involving multiple comparisons, and it is, therefore, possible that some of the findings may simply have arisen by chance. A further limitation is that nausea was scored as “all or none” and not graded in the same way as headache pain; thus, mild nausea carried equal weight to severe nausea. While we cannot be sure that all groups were equally matched with regard to severity of nausea, this was a large analysis involving more than 4000 patients who were randomly assigned to treatment. It is, therefore, reasonable to expect that patients with differing nausea severity would have been approximately equally distributed between the treatment groups by the randomization process. Nevertheless, these results require replication in future prospective studies where patients are required to grade both nausea and pain on a 4-point scale."¹

The authors conclude:

"Our analysis underscores that the proportion of patients with nausea at specified time points following treatment is determined by a number of factors. These include the proportion with nausea at baseline, the spontaneous remission of nausea, the influence of treatment on relieving nausea, the spontaneous emergence or exacerbation of nausea, and the influence of treatment on the emergence or exacerbation of nausea. Most studies do not attempt to disentangle these five factors. We have presented an analytic strategy which shows that about 60% of patients have nausea at baseline. Based on placebo rates, about a third to a half of patients with baseline nausea experience a remission of nausea by 2 hours. In general, triptans effectively relieve nausea, although rizatriptan (Maxalt) is more effective (about two thirds [66% to 68%] of patients with baseline nausea have nausea relief) compared with sumatriptan (Imitrex) (57% to 59%) and naratriptan (Amerge) (45%). Nausea emerges spontaneously in about a tenth of placebo-treated moderate or severe migraine attacks. In general, triptans have minimal effects on emergent nausea."¹

If you experience Migraine symptom nausea, are taking a triptan drug, and your nausea is not relieved, try some of the other triptans. Just as they are differently effective for the relief of other Migraine symptoms, this study has shown that they are differently effective for the relief of nausea. Should you find that none of them effectively relieve your nausea, you may want to choose the triptan that is most effective for relieving other symptoms. Then, discuss other methods or medications for the relief of nausea.

 

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