When a migraine hits, you don’t want to wait. You want relief-fast. But not all relief comes without risk. The three main classes of acute migraine meds-triptans, gepants, and ditans-work differently, and their safety profiles aren’t the same. Choosing the right one isn’t just about which works best. It’s about which is safest for you.
Triptans: Fast, Effective, But Not for Everyone
Triptans have been the gold standard since sumatriptan hit the market in 1991. They work by tightening blood vessels around the brain and blocking pain signals. That’s why they often knock out a migraine in under an hour. But that same mechanism is also their biggest flaw.
Triptans activate 5-HT1B receptors, which cause vasoconstriction. That’s fine for most people-but if you have heart disease, uncontrolled high blood pressure, a history of stroke, or peripheral artery disease, this can be dangerous. The American Academy of Family Physicians explicitly advises against using triptans in these cases.
Even if you’re otherwise healthy, side effects are common. About 1 in 5 people feel chest tightness or pressure after taking a triptan. It’s not a heart attack, but it’s terrifying enough to make many quit. Other frequent complaints: tingling in fingers or face, dizziness, flushing, and extreme fatigue. One user on Drugs.com wrote: "Experienced severe chest pressure with first dose of Imitrex-never using it again."
Some triptans are better tolerated than others. Almotriptan and frovatriptan tend to cause fewer side effects. Subcutaneous sumatriptan causes injection-site pain in 40% of users. Nasal sprays leave a bitter aftertaste for about a quarter of people. Still, for many, the trade-off is worth it. Triptans are still prescribed in 62% of acute migraine cases.
Gepants: The New Kid on the Block With Fewer Risks
Gepants-like ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT)-are a different kind of drug. Instead of squeezing blood vessels, they block CGRP, a protein linked to migraine pain. No vasoconstriction means no cardiovascular red flags. That’s why neurologists now recommend gepants over triptans for patients with heart risks.
Side effects? Minimal. Nausea happens in just 4-6% of users. Drowsiness? Around 2-4%. Hypersensitivity reactions are rare-only 0.1% with rimegepant. No chest tightness. No tingling. No dizziness that knocks you off your feet.
But there’s a catch: speed. Triptans often work within 30 minutes. Gepants? Usually take 1-2 hours. If you need to get back to work or pick up your kids right away, that delay matters. Still, many users prefer the gentler experience. One review on Drugs.com says: "No chest pressure like with triptans, just takes longer to work."
Long-term safety looks promising. Rimegepant has two years of data showing it’s safe for regular use. Ubrogepant’s data is shorter, but still clean. The only caution? Avoid rimegepant with strong CYP3A4 inhibitors like ketoconazole-they can spike drug levels in your blood. Otherwise, it’s one of the safest acute migraine treatments available today.
Ditans: Powerful, But Too Sedating for Daily Use
Lasmiditan (Reyvow) is the only ditan on the market. It targets 5-HT1F receptors, which means no blood vessel narrowing. That’s a win for heart safety. But it hits the brain harder in other ways.
In clinical trials, 18.8% of people taking lasmiditan felt dizzy. Nearly 10% had tingling. Almost 8% were so sedated they couldn’t function. Fatigue, muscle weakness, and even cognitive fog showed up more often than with placebo. One Reddit user summed it up: "Reyvow made me feel drunk without alcohol."
Because of this, the FDA requires a black box warning: Do not drive or operate machinery for at least 8 hours after taking Reyvow. That’s not a suggestion. It’s a rule. If your job involves any kind of alertness-driving, operating equipment, even caring for kids-lasmiditan isn’t practical.
It’s also not recommended if you have a history of seizures or take other drugs that lower your seizure threshold. While no clear link to seizures has been proven, the risk is theoretical enough that doctors avoid it in high-risk patients.
With a 5.8/10 rating on Drugs.com and 63% of negative reviews citing dizziness or sedation, ditans are the least popular of the three. They’re reserved for patients who can’t use triptans and don’t respond to gepants. Even then, many doctors try them only once.
Comparing the Three: Safety at a Glance
A 2021 analysis of 64 clinical trials involving over 46,000 people found clear patterns:
| Side Effect | Triptans | Gepants | Ditans (Lasmiditan) |
|---|---|---|---|
| Any adverse event (vs placebo) | 1.8x higher | 1.3x higher | 2.9x higher |
| Chest tightness | 3-8% | <1% | <1% |
| Dizziness | 7-14% | 2-4% | 18.8% |
| Sedation | 6-10% | 2-4% | 7.8% |
| Nausea | 5-12% | 3-6% | 5.0% |
| Cardiovascular risk | Contraindicated in heart disease | Safe for heart patients | Safe for heart patients |
| Driving restriction | No | No | Yes (8+ hours) |
Bottom line: Gepants have the cleanest safety profile. Ditans are the most sedating. Triptans are the most effective-but carry the most risk for certain people.
What Experts Say About the Trade-Offs
Dr. Elizabeth Loder from Harvard Medical School put it bluntly: "Based on my clinical experience, I don’t think that any of these drugs would do a lot better than the triptans" for overall benefit. She’s not saying they’re perfect-just that their effectiveness still wins for many.
But Dr. Rami Burstein, also from Harvard, warns that lasmiditan’s sedation makes it a poor choice for people who need to function after taking it. "It limits its utility as a first-line agent," he said.
The American Headache Society now recommends gepants as the preferred option for patients with cardiovascular issues. That’s a big shift from just five years ago.
Real-World Use: What People Actually Experience
Numbers don’t tell the whole story. Real people do.
On Drugs.com:
- Triptans: 6.4/10 average rating. 52% positive. Common complaint: chest pressure.
- Gepants (Nurtec): 7.1/10. 68% positive. Common praise: "No scary side effects."
- Ditans (Reyvow): 5.8/10. Only 37% positive. 63% of negatives mention dizziness or "feeling out of it."
On Reddit’s r/Migraine, triptan side effects come up in 78 posts in a single month. Lasmiditan’s sedation appears in 31. Gepants? Only 42 mentions-mostly positive.
People aren’t just choosing based on efficacy. They’re choosing based on whether they can still be parents, employees, drivers, or students after taking the pill.
Practical Safety Tips
- If you have heart disease or high blood pressure: Avoid triptans. Gepants are your safest bet.
- If you need to drive or work after taking your med: Skip lasmiditan. It’s not worth the risk.
- If nausea is a problem: Rimegepant (Nurtec) has the lowest nausea rate among all three.
- If you’re on other meds: Check for interactions. Rimegepant shouldn’t be taken with strong CYP3A4 inhibitors like ketoconazole or clarithromycin.
- Don’t combine triptans with dihydroergotamine: Wait at least 24 hours between doses. Both cause vasoconstriction.
- Don’t assume side effects are "just the migraine": The Medical Letter points out that fatigue, dizziness, and weakness can be part of the migraine attack itself-not the drug. Keep a symptom log to tell the difference.
What’s Next?
There’s new hope on the horizon. Zavegepant, an intranasal gepant, just finished Phase 3 trials with a side effect rate of just 12.3%-lower than placebo. It could offer fast relief without pills or injections.
Long-term safety data for gepants beyond two years is still limited. But rimegepant’s two-year data is reassuring. Triptans? We’ve had 30+ years of data. Ditans? We’ve had less than five.
For now, the choice comes down to your body, your life, and your priorities. If you need speed and have no heart issues, triptans still win. If safety and tolerability matter more, gepants are the future. Ditans? They’re a backup plan-not a first choice.
Are gepants safer than triptans for people with heart problems?
Yes. Gepants don’t cause blood vessel narrowing, so they’re safe for people with heart disease, high blood pressure, or a history of stroke. Triptans are contraindicated in these cases because they can trigger heart attack or stroke. The American Headache Society recommends gepants over triptans for patients with cardiovascular risks.
Can I drive after taking lasmiditan?
No. The FDA requires a warning that you must not drive, operate machinery, or do anything requiring full alertness for at least 8 hours after taking lasmiditan. Clinical studies show significant impairment in reaction time and coordination. Many users report feeling "drunk without alcohol." It’s not worth the risk.
Why do triptans cause chest tightness?
Triptans activate serotonin receptors that cause blood vessels to constrict-including those in the heart. This can feel like chest pressure or tightness, even if there’s no actual heart damage. It’s a common side effect, not a heart attack. But because it mimics one, doctors still advise caution in people with heart conditions.
Which migraine medication has the fewest side effects?
Gepants-especially rimegepant (Nurtec)-have the lowest rate of side effects. Nausea affects under 6% of users, dizziness under 4%, and there’s no chest tightness or sedation risk. They’re the safest option overall, especially for long-term or frequent use.
Are ditans better than triptans?
Only if you can’t take triptans due to heart issues. Ditans don’t constrict blood vessels, so they’re safer for your heart. But they cause much higher rates of dizziness, sedation, and cognitive fog. Most people can’t function normally after taking them. For most patients, triptans still offer a better balance of speed and tolerability-if they’re safe for you.
Can I take gepants every day?
Rimegepant (Nurtec) is approved for both acute and preventive use. You can take it every other day, up to 18 times per month. Ubrogepant is only approved for acute use (up to 8 times per month). Long-term safety beyond two years isn’t fully known, but current data shows no major red flags.
Final Thoughts
Migraine treatment isn’t one-size-fits-all. What works for your neighbor might leave you dizzy or scared. The best medication isn’t the one that works fastest-it’s the one you can take without fear, without guilt, and without losing your day.
Triptans are still powerful. Gepants are safer. Ditans are too sedating for most. Your job isn’t to pick the newest drug. It’s to pick the one that lets you live your life-without side effects that feel worse than the migraine itself.
