Almotriptan in Migraine Patients Who Respond Poorly to Oral Sumatriptan: A Double-Blind, Randomized Trial

Abstract

Objective: To investigate the efficacy and tolerability of almotriptan 12.5 mg in migraine patients who respond poorly to sumatriptan 50 mg. Background: Poor response to sumatriptan therapy for acute migraine attacks has been documented in the literature, but few controlled trials have investigated the efficacy of an alternative triptan in this subgroup of patients. Methods: Patients with an International Headache Society diagnosis of migraine who self-described as experiencing at least two unsatisfactory responses to sumatriptan treated their first migraine attack with open-label sumatriptan 50 mg. Patients who did not achieve 2-hour pain relief (improvement of headache from moderate/severe to mild/no headache) were then randomized to treat their second attack with almotriptan 12.5 mg or placebo under double-blind conditions. Results: In the first attack, 221 of 302 participants (73%) did not achieve 2-hour pain relief with sumatriptan and were randomized to treatment of their second attack with almotriptan 12.5 mg or placebo. Of the 198 sumatriptan nonresponders who treated their second attack (99 almotriptan; 99 placebo), 70% had severe headache pain at baseline. Two-hour pain-relief rates were significantly higher with almotriptan compared to placebo (47.5 vs. 23.2%; p < 0.001). A significant treatment effect for almotriptan was also seen in pain-free rates at 2 h (33.3 vs. 14.1%; p < 0.005) and sustained freedom from pain (20.9 vs. 9.0%; p < 0.05). In the second attack, 7.1% of patients in the almotriptan group experienced adverse events compared to 5.1% in the placebo group (p = 0.77). Conclusions: Almotriptan 12.5 mg is an effective and well-tolerated alternative for patients who respond poorly to sumatriptan 50 mg. A poor response to one triptan does not predict a poor response to other agents in that class.

Fixed‐Dose Sumatriptan and Naproxen in Poor Responders to Triptans With a Short Half‐Life

“…In this respect, the current studies differ from previous nonresponder studies, which assessed a therapeutic alternative to only one triptan monotherapy, which was most often sumatriptan. 4,[35][36][37][38][39] The results of these studies should nevertheless be generalized cautiously to triptans other than eletriptan as approximately two-thirds of patients had failed eletriptan rather than other triptans.…”

“…In other studies, poor responders to triptans were asked to treat moderate or severe pain or to treat at any level of pain severity. 4,[33][34][35][36][37][38][39] Early intervention compared with waiting to treat moderate or severe pain appears to increase the probability of rapid pain-free outcomes, reduce the frequency of migraine recurrence, and decrease the rescue medication use. [19][20][21][22][23][24][25][26][27][28][29][30] Conversely, administration of medication late during the course of a migraine attack is one factor that has been linked to poor response to triptans.…”

EFNS guideline on the drug treatment of migraine – revised report of an EFNS task force

“…Some minor differences between triptans exist which will be discussed in order to give a guidance which triptan to use in an individual patient. A triptan can be efficacious even if another triptan was not [67,68].…”

Triptan Nonresponder Studies: Implications for Clinical Practice

“…1 On a positive note, however, evidence from clinical trials indicate that patients with a poor response to one triptan can benefit from subsequent treatment with a different triptan. [7][8][9][10]…”