When a migraine hits, speed and safety matter. You don’t just want relief-you want relief without risking your heart, your focus, or your ability to drive home. Three classes of acute migraine meds-triptans, gepants, and ditans-offer different trade-offs. Understanding their safety profiles isn’t just academic; it can mean the difference between getting back to your day and ending up in the ER.
Triptans: Fast, Effective, But Not for Everyone
Triptans like sumatriptan, rizatriptan, and almotriptan have been the go-to for decades. They work fast-often cutting pain in half within an hour. That’s why they’re still used in over 60% of acute migraine cases. But their mechanism comes with a cost.
Triptans activate serotonin receptors that narrow blood vessels. That’s helpful for migraine, but dangerous if you have heart disease, uncontrolled high blood pressure, or a history of stroke. The American Academy of Family Physicians explicitly warns against using them in these patients. Even if you’re otherwise healthy, you might feel it: chest tightness, flushing, dizziness, or tingling in your hands and face. About 3-8% of users report that crushing chest pressure, and many never take it again after the first dose.
Some side effects are just annoying. Subcutaneous injections cause pain at the site in 40% of users. Nasal sprays leave a bitter aftertaste for a quarter of people. Fatigue and drowsiness are common too. But here’s something important: not every symptom you feel after taking a triptan is caused by the drug. Sometimes, it’s just the migraine itself acting up-like brain fog or weakness. That’s why doctors look at patterns over time, not just one bad reaction.
Still, the data doesn’t lie. In a 2021 analysis of 46,000+ patients across 64 trials, triptans had a higher rate of side effects than newer options. About 1 in 4 users reported something unpleasant. That’s why many stop taking them-even when they work. The JAMA Network Open study found that 55% to 81% of people discontinue triptans due to side effects or fear of risks.
Gepants: The Quiet Contender With Fewer Risks
Gepants-like ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT)-are the new kids on the block. Approved in late 2019, they block a protein called CGRP, which plays a key role in migraine pain. Unlike triptans, they don’t constrict blood vessels. That makes them safe for people with heart conditions who can’t use triptans.
Side effects? Minimal. Nausea happens in just 4-6% of users. Drowsiness affects only 2-4%. There’s a tiny risk of allergic reaction with rimegepant-about 1 in 1,000. No chest tightness. No tingling. No risk of heart attack or stroke from the drug itself.
But they’re slower. Triptans often work in 30 minutes. Gepants take 60 to 90 minutes. If you need to get back to work fast, that’s a real drawback. Still, they last longer. Rimegepant’s half-life is 10-12 hours, meaning it can prevent a rebound headache better than most triptans, which wear off in 2-14 hours.
Real-world feedback backs this up. On Drugs.com, rimegepant has a 7.1/10 rating from nearly 700 users. One person wrote: “No chest pressure like with triptans, just takes longer to work.” That’s the trade-off: patience for peace of mind.
There’s one catch: drug interactions. Rimegepant shouldn’t be taken with strong CYP3A4 inhibitors like ketoconazole or grapefruit juice. These can spike the drug’s levels in your blood. Always tell your doctor what else you’re taking.
Ditans: Powerful But Paralyzing
Lasmiditan (Reyvow) is the only ditan on the market. It targets a different serotonin receptor-5-HT1F-so it doesn’t affect blood vessels at all. That means it’s safe for people with heart disease. But it hits your brain hard.
In clinical trials, 18.8% of people taking a standard 100mg dose of lasmiditan felt dizzy. That’s nearly double the placebo rate. Paresthesia (tingling or numbness) hit 9.4%. Sedation? 7.8%. Vertigo? 5.6%. One in three users reported feeling “out of it.”
The FDA requires a black box warning: Do not drive or operate machinery for at least 8 hours after taking Reyvow. A 2021 study showed people were still impaired at the 5-hour mark. That’s not just inconvenient-it’s dangerous. One Reddit user summed it up: “Reyvow made me feel drunk without alcohol.”
It’s not just dizziness. Muscle weakness, fatigue, and cognitive fog are common. In trials, 2.8% of users reported cognitive changes-things like trouble remembering words or focusing. That’s not normal for most migraine sufferers. It’s the drug.
It also carries a theoretical risk for seizures, especially if you’re already on medications that lower your seizure threshold. The Medical Letter advises avoiding it in people with epilepsy or a history of seizures, even though direct evidence is limited.
With an average rating of 5.8/10 on Drugs.com and 63% of negative reviews citing dizziness or sedation, it’s clear: ditans are not for everyone. They’re reserved for patients who can’t use triptans and need something faster than gepants-but only if they can afford to be out of commission for half a day.
Comparing Safety: A Quick Snapshot
| Medication Class | Cardiovascular Risk | Common Side Effects | Onset of Action | Best For |
|---|---|---|---|---|
| Triptans | High-contraindicated in heart disease | Chest tightness, tingling, dizziness, fatigue | 30-60 minutes | Healthy patients needing fast relief |
| Gepants | Very low-safe for heart patients | Nausea (4-6%), drowsiness (2-4%) | 60-90 minutes | Patients with cardiovascular risks or long-term use |
| Ditans | None | Dizziness (18.8%), sedation (7.8%), cognitive fog | 60-90 minutes | Heart patients who can afford to be sedated for 8+ hours |
The numbers tell a clear story. Ditans have the highest overall risk of side effects-almost 3 times more than placebo. Triptans are next. Gepants? Lowest risk by far. But speed and effectiveness matter too. Triptans still win in pain relief at the 2-hour mark. Gepants catch up by 24 hours. Ditans? They relieve pain, but you might not remember how.
What Doctors Really Think
Dr. Elizabeth Loder from Harvard says: “Based on my clinical experience, I don’t think any of these drugs would do a lot better than the triptans” for overall benefit. That’s not because triptans are perfect. It’s because they’re reliable. When they work, they work fast. And for many, that’s worth the risk.
But for others? Not even close. Dr. Rami Burstein points out that lasmiditan’s sedation makes it a poor choice for anyone who needs to function after taking it-parents, drivers, office workers. “It’s not a rescue drug,” he says. “It’s a retreat drug.”
That’s why guidelines are shifting. The American Headache Society now recommends gepants over triptans for patients with cardiovascular risks. It’s not about being trendy-it’s about matching the tool to the person.
Real-Life Decisions
If you’re young, healthy, and your migraines hit like a freight train? Triptans might still be your best bet. Just know the signs of trouble: chest pain, jaw tightness, sudden shortness of breath. Stop the drug and call your doctor.
If you have high blood pressure, angina, or a history of stroke? Skip triptans. Gepants are your safest bet. They’re not perfect, but they’re the closest thing to a clean slate.
If you’ve tried both and still get debilitating migraines? Lasmiditan might be an option-but only if you can plan for a full day off. No driving. No childcare. No work. Just rest.
And if you’re unsure? Talk to your neurologist. Bring your symptom log. Ask: “Which of these has the lowest risk for me?” Because safety isn’t one-size-fits-all.
What’s Coming Next
Zavegepant, a new intranasal gepant, just finished phase 3 trials with a safety profile similar to oral gepants-no vasoconstriction, minimal sedation. It could be available soon, giving people another fast-acting, heart-safe option.
Long-term data is still limited. Only rimegepant has 2-year safety data. The rest? We’re watching. The FDA’s adverse event reports show fewer issues with gepants than triptans, but we need more years.
For now, the choice is clear: know your body, know your risks, and match the drug to your life-not the other way around.
Are triptans safe if I have high blood pressure?
No. Triptans cause blood vessels to narrow, which can raise blood pressure and trigger heart problems. If you have uncontrolled hypertension, heart disease, or a history of stroke, you should avoid them. Gepants are the safer alternative.
Can I drive after taking lasmiditan?
No. The FDA requires you to avoid driving, operating machinery, or doing anything requiring full alertness for at least 8 hours after taking lasmiditan. Many people feel drowsy, dizzy, or mentally foggy for that long-even if they feel fine.
Do gepants cause weight gain or liver damage?
No. Unlike some older migraine preventives, gepants have not been linked to weight gain or liver damage in clinical trials. The most common side effects are mild nausea and drowsiness. Long-term safety beyond 2 years is still being studied, but no major red flags have emerged.
Why are gepants more expensive than triptans?
Gepants are newer and still under patent protection, so they cost more upfront. But if you’ve had to stop triptans due to side effects or heart risks, the cost may be worth it-especially if you avoid ER visits or missed workdays. Some insurance plans cover them with low copays now.
Can I take a gepant and a triptan together?
No. There’s no proven benefit, and combining them increases your risk of side effects without clear advantage. Stick to one acute treatment per attack. If one doesn’t work, wait at least 24 hours before trying another class.
Is it safe to use these meds long-term?
Triptans are generally safe for occasional use (under 10 days/month). Overuse can lead to rebound headaches. Gepants like rimegepant are approved for both acute and preventive use up to 18 times per month. Long-term safety beyond 2 years is still being studied, but no major safety issues have emerged so far.
What to Do Next
Write down your migraine pattern: how often they hit, how long they last, what makes them better or worse. Note any side effects you’ve had from past meds. Bring this to your doctor.
Ask: “Which of these three options is safest for my health history?” Don’t settle for the first prescription. Ask about alternatives. Ask about cost. Ask about real-life impact.
Migraine treatment isn’t about finding the best drug. It’s about finding the right drug-for your body, your life, and your future.