When should triptans be taken during a migraine attack?

The common strategy to treat a migraine attack as soon as it begins, made for classical acute antimigraine treatments such as ergotamine and analgesics, has not been transposed to the triptans. The recommendation to delay triptan intake until headache intensity is at least moderate is merely a habit generated by the protocol used in triptan trials and a nonvalidated attempt to reduce costs. It is also favoured by the few studies suggesting that sumatriptan is less effective when given early in an attack, especially during the aura phase. Recent retrospective analyses of small numbers of 'protocol violators' in controlled trials of sumatriptan suggest that the drug is more efficient when taken while the headache is mild. Pain-free responses and therapeutic gains over aspirin (acetylsalicylic acid)-metoclopramide or ergotamine-caffeine combinations were increased under these conditions. The available circumstantial evidence is reviewed and discussed. Before any conclusion can be drawn and recommendation made, results are awaited from randomised controlled trials specifically addressing whether or not triptans are more efficient in mild headache. Meanwhile, there seems to be no medical reason to withhold treatment of a mild headache with a triptan as long as triptan intake does not exceed 1 or 2 doses per week. Most mild headaches in patients with migraine appear indeed to be mild migraine attacks, even when the headache characteristics are those of tension-type headache.