When a migraine hits, you don’t want to wait. You want relief-fast. But you also don’t want to trade one problem for another. That’s why safety matters just as much as speed when choosing a migraine medication. Three main classes of drugs are used today: triptans, gepants, and ditans. Each works differently, and each comes with its own set of risks. Knowing the difference can help you pick the right one-or avoid the wrong one.
Triptans: Fast but With a Price
Triptans like sumatriptan (Imitrex), rizatriptan (Maxalt), and almotriptan (Axert) have been the go-to for decades. They work by tightening blood vessels around the brain and blocking pain signals. For many, they’re the fastest option-often working in under 30 minutes. But that speed comes with side effects.
Up to 15% of people report tingling, flushing, or a tight, heavy feeling in the chest. That chest sensation is real, even if it’s not a heart attack. Still, it scares people. One user on Drugs.com wrote: "Experienced severe chest pressure with first dose of Imitrex-never using it again." That’s not rare. Around 3-8% of users report this sensation in clinical trials.
The bigger concern is cardiovascular risk. Triptans cause blood vessels to narrow. That’s fine for most people. But if you have high blood pressure, heart disease, a history of stroke, or uncontrolled migraines with aura, they’re not safe. The American Academy of Family Physicians says they’re contraindicated in these cases. And even if you’re healthy, you can’t take them within 24 hours of other vasoconstrictors like dihydroergotamine.
There’s also the route of delivery. Subcutaneous sumatriptan causes injection-site pain in 40% of users. Nasal sprays leave a bitter aftertaste for about a quarter of people. Fatigue and dizziness are common, too. Still, the overall risk of serious events like heart attack or stroke is low-about the same as placebo, according to a 2016 meta-analysis. But the discomfort? That’s where most people stop using them.
Gepants: The Quiet Contender
Gepants like ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT) are newer. They block CGRP, a molecule involved in migraine pain, without touching blood vessels. That’s why they’re the safest option for people with heart problems.
Side effects? Mild. Nausea happens in only 4-6% of users. Drowsiness? Around 2-4%. One rare case of allergic reaction was reported with rimegepant, but it’s extremely uncommon. No chest tightness. No blood vessel narrowing. No restrictions for people with cardiovascular disease.
But there’s a trade-off: speed. Triptans work faster. In head-to-head studies, triptans beat gepants at the 2-hour mark. Gepants take longer to kick in-sometimes 60 to 90 minutes. But they last longer. Ubrogepant sticks around for 5-7 hours. Rimegepant lasts 10-12 hours. That means fewer headaches coming back later.
Users notice this. On Drugs.com, rimegepant has a 7.1/10 rating. One user said: "No chest pressure like with triptans, just takes longer to work." That’s the common theme: slower, but cleaner. And for people who’ve quit triptans because of side effects, gepants are often the first thing their doctor suggests.
One caution: rimegepant shouldn’t be taken with strong CYP3A4 inhibitors like ketoconazole. That can raise drug levels dangerously. But for most people, that’s not an issue.
Ditans: Powerful, But Too Sedating
Lasmiditan (Reyvow) is the only ditan approved so far. It works on a different serotonin receptor-5-HT1F-so it doesn’t constrict blood vessels. That makes it safe for people with heart conditions, just like gepants.
But here’s the catch: it hits the brain hard. In clinical trials, 18.8% of people on lasmiditan 100mg reported dizziness. Compare that to 8.5% on placebo. Paresthesia (tingling or numbness)? 9.4%. Sedation? 7.8%. Vertigo? 5.6%. Muscle weakness? 2.8%. Cognitive fog? 2.8%.
It’s not just numbers. Real people describe it as feeling "drunk without alcohol." One Reddit user got 147 upvotes for a post titled: "Reyvow made me feel drunk without alcohol." Others said they couldn’t drive, couldn’t work, couldn’t even sit up straight for hours.
The FDA requires a warning: don’t drive or operate machinery for at least 8 hours after taking it. That’s not a suggestion. That’s a rule. And it’s not just theoretical. A 2021 study in Headache showed clear driving impairment at the 5-hour mark.
It’s also not recommended if you’ve had seizures or take other drugs that lower your seizure threshold-though actual cases of seizures from lasmiditan are rare. Still, doctors avoid it unless other options fail.
On Drugs.com, lasmiditan averages 5.8/10. Sixty-three percent of negative reviews mention dizziness or sedation. That’s why it holds only 3% of the acute migraine market-despite being safe for the heart.
Which One Is Safest Overall?
A 2021 analysis of 64 clinical trials with over 46,000 people found clear patterns:
- Ditans had the highest risk of any side effect-almost 3 times more than placebo.
- Triptans came next-about 40% more side effects than placebo.
- Gepants had the lowest risk-closest to placebo, with the fewest complaints.
For cardiovascular safety, gepants win. They don’t touch blood vessels. Triptans are out for anyone with heart disease. Ditans are safe for the heart, but they knock you out.
For speed, triptans still lead. For lasting relief, gepants are better. For people who need to drive or work after taking medication? Gepants are the only realistic choice.
Doctors aren’t abandoning triptans. Dr. Elizabeth Loder from Harvard says, "I don’t think any of these drugs would do a lot better than the triptans" for overall benefit. But she’s also quick to add: "For patients with heart disease or who can’t tolerate side effects, we have better options now."
Real-World Use and Trends
Even with all the new options, triptans still make up 62% of migraine prescriptions. But gepants are climbing fast-from 2% in 2020 to 28% by late 2023. Ditans? Only 3%. Why? Because safety and function matter more than novelty.
The American Headache Society now recommends gepants over triptans for patients with cardiovascular risk. That’s a big shift. And it’s backed by data.
Long-term safety? That’s still being studied. Rimegepant has two years of data showing it’s safe for regular use. Other gepants? Not yet. But no red flags so far.
And new options are coming. Zavegepant, an intranasal gepant, finished its phase 3 trial in 2023 with a side effect rate of just 12.3%-lower than most oral drugs. No vasoconstriction. No sedation. Just fast, clean relief.
What Should You Do?
If you’re taking triptans and they work without side effects? Keep going. They’re still effective.
If you’ve stopped triptans because of chest tightness, dizziness, or heart concerns? Talk to your doctor about gepants. They’re safer, and many people find them easier to live with.
If you’ve tried everything and still get severe migraines? Ditans might be an option-but only if you can afford to be out of commission for half a day. Don’t take them before work, school, or driving.
And remember: some symptoms you think are side effects might actually be part of the migraine itself. Nausea, fatigue, dizziness-they can be symptoms of the attack, not the drug. That’s why doctors ask you to track what happens when you take the medication. Not just how you feel, but when.
There’s no perfect migraine drug. But there is a best one-for you. It depends on your body, your life, and your risks. Don’t just pick the newest. Pick the safest for you.
Are triptans safe if I have high blood pressure?
No. Triptans cause blood vessels to narrow, which can raise blood pressure and increase the risk of heart attack or stroke in people with uncontrolled hypertension, heart disease, or a history of stroke. They’re contraindicated in these cases. Always tell your doctor your full medical history before starting any migraine medication.
Can I take gepants if I’ve had a heart attack?
Yes. Gepants like ubrogepant and rimegepant don’t affect blood vessels, so they’re considered safe for people with a history of heart attack, angina, or other cardiovascular conditions. They’re often the preferred choice for these patients. Always confirm with your doctor, but in most cases, they’re the safest acute option.
Why does lasmiditan make me feel drunk?
Lasmiditan acts on serotonin receptors in the brain that affect coordination, balance, and alertness. It doesn’t cause intoxication like alcohol, but it can cause dizziness, sedation, and cognitive fog-side effects that feel similar. That’s why the FDA requires a warning: don’t drive or operate machinery for at least 8 hours after taking it.
Which migraine drug has the least side effects?
Gepants have the lowest rate of side effects among the three classes. Nausea and drowsiness are mild and uncommon. No chest tightness, no dizziness, no driving restrictions. In clinical trials, they were closest to placebo in terms of adverse events. If you want the cleanest profile, gepants are your best bet.
Can I switch from triptans to gepants safely?
Yes. Many people switch successfully. There’s no required washout period. You can start a gepant the next time you have a migraine. Some people notice it takes longer to work, but they appreciate the lack of chest pressure or dizziness. Talk to your doctor about dosing, especially if you’re taking other medications.
What to Watch For
Keep a headache diary. Note:
- When you took the medication
- How long it took to work
- What side effects you felt
- Whether you could function afterward
That data helps your doctor decide what to try next. If you feel chest pressure, don’t ignore it-even if you’re told it’s "just a side effect." If you feel too drowsy to drive, don’t get behind the wheel. If you’re not getting relief, don’t keep taking more. Talk to your doctor. There are options.
Migraines are complex. So are the drugs we use to treat them. But you don’t have to guess. With the right information, you can find a treatment that works-without putting your health at risk.
