Triptans Commonly Ineffective for Migraine in Primary Care

Triptan failure may occur in more than one-quarter of adults with migraine in primary care, either due to contraindications to triptan therapy or lack of efficacy, according to study results published in The Journal of Headache and Pain.

Migraine, which is managed most often in primary care settings, is the second leading cause of disability worldwide. While triptans are a cornerstone of acute migraine treatment, they are neither universally effective nor appropriate for all patients. Despite updated guidance from the European Headache Federation, the true burden of triptan failure in general practice remains incompletely characterized, particularly outside of tertiary care settings.

Researchers conducted a retrospective cohort analysis to quantify the prevalence and management of triptan failure among patients with migraine seen by general practitioners (GPs) from 2017 to 2022. Adult patients with migraine or a prescription for migraine-specific medications and at least 5 years of medical history were included. Triptan failure was defined as either ineligibility (due to cardiovascular or other contraindications or age 65 years and older) or resistance (based on the failure of 2 different triptans followed by a third acute treatment). National prevalence was estimated via extrapolation, which revealed that in 2022 in metropolitan France, 2.78% of the French population (1,440,169 adults) consulted a GP for migraine.

Among 16,888 eligible adult patients, 4509 (26.7%) met criteria for triptan failure. This included 4024 patients with triptan ineligibility, comprising 1364 (8.1%) patients with cardiovascular contraindications, 700 (4.1%) with other contraindications, and 2055 (12.2%) aged 65 years and older. Another 604 (3.6%) patients were determined to have triptan resistance based on prescribing patterns. Strikingly, more than half (53.9%) of triptan-ineligible patients continued to receive triptan prescriptions after the onset of contraindications, including 56.2% of those with cardiovascular contraindications and 54.9% of those aged 65 years and older.

Management decisions regarding patients with triptan-resistant revealed significant treatment complexity. Nearly half (45.2%) of patients were prescribed a third triptan, while 55.0% were switched to a nontriptan acute therapy. Nonsteroidal anti-inflammatory drugs were used in 74.8% of patients with triptan resistance, and 80.3% received triptans in combination with other acute agents. Despite previous treatment failures, 6.8% of patients with triptan resistance were prescribed 4 or more different triptans over time.

Limitations of the study include the inability to assess triptan intolerance due to database constraints, potential underestimation of resistance in patients who did not receive a 3rd acute treatment, reliance on prescribing proxies rather than documented clinical efficacy, and the exclusion of newly emerging cases as resistance was only assessed during a fixed 5-year period.

The researchers concluded, “These observations could highlight either a lack of awareness of contraindications among GPs or a therapeutic dilemma for these patients, leaving no alternative but to attempt triptan despite contraindications.” They added, The unmet therapeutic need remains substantial, warranting further research and tailored approaches to improve patient outcomes.”

Disclosure: This study was sponsored by Pfizer. Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.

This article originally appeared on Clinical Pain Advisor