The Bounce

by Maria on October 14, 2008

First, may I say the triptans are a marvelous class of drug? When you’re wading through a 5 day migraine and liquids, not to mention solid food, are a distant memory. When the right side of your brain wakes you up every hour or two to pound a little harder on the left. When you haven’t been able to complete a sentence for days, but that’s just fine as you can’t leave your house to find any humans to talk to and you wouldn’t be able to find your way back home anyway. When you know, you just know that there’s one last zomig in the house if only you could find it. And then you do.

Joan Didion wrote that she came to regard her enemy, migraine, as a friend. Susan Sontag pointed out that describing illness with military metaphors has certain failings, not the least of which is to make ill people feel defeated. I don’t hold with making an ally of migraine, but I will grant you that the first day after the enemy decamps is a Red Letter Day. Today I am so full of vim and vigour that it seems a shame to waste all that energy on work. (Sadly I have so much to catch up on, I’ll have to.) The world is a bright, clear and shiny place today, even if my 401(k) is worth 53% less than what I’ve spent on it. So be it. Feeling like this, I could work until I’m 106, rather like that cheery nun who hasn’t cast a vote since Eisenhower, and who’s thrown her veil in the ring for Obama.

To business; why are triptans so expensive? Fair enough that nobody knows whether migraines are caused by bad chemistry or bad wiring. (Presumably it all looks the same at the molecular level.) So we’re not quite sure why triptans work so well for some people. But when they work, they are transformative within minutes. In Belgium, a month’s supply used to cost me about $100. Here in the US, my gold-plated insurer gives them to me more or less free. But someone’s making a lot of money either way, and migraine has such a huge impact on productivity/absenteeism that getting the cure for cheap would help hundreds of thousands of people and their employers. When did we invent this miracle drug, and will we be sharing the bounty any time soon?



fjm 10.14.08 at 7:55 pm

When I very first took sumatriptan, way back in 1993, I used to describe it to friends as “butterflies coming out”. After a decade of untreatable migraine, it was liberating.


Maria 10.14.08 at 7:57 pm

I’m sure there’s a good haiku in there somewhere.


matt 10.14.08 at 8:08 pm

Imitrex changed my life (it helped me just this morning, in fact) by letting me get by and even feel fine on what used to be days (5-10 a month, sometimes, less these days) where I knew the whole day would be shot. Where I used to be filled with dread when I’d start feeling a migraine coming on, now, so long as I have a supply, it’s not a worry. (The injections are the best as the work in seconds but since my insurance thinks two injections should cost as much as 9 pills, despite having [and needing] much less of the drug, I don’t use them as often.) It really is wonderful stuff that greatly, greatly increased the quality of my life after several years of unpleasantness. I should do commercials for the stuff.


Tom Womack 10.14.08 at 9:10 pm

This is a boringly concrete answer: the patent was awarded in 1992, so cheap generic triptans should be available in the US by the end of next year. I can find a 1989 paper which seems to describe a triptan migraine medicine, and given the normal drug-design timescale I assume that the work started in the mid-seventies.


harry b 10.14.08 at 9:12 pm

I haven’t read the Didion, but I will. I have two afflictions that have come to be so familiar to me that I do kind of regard them as friends; gout, which I have completely under control with medication but which I can tell will get more difficult as I age (my first attack I was 25, which is quite young), and pneumonia, which I get regularly and which, I figure, will get me in the end (if I’m lucky enough not to be got by some other, less amicable condition, first). Its the familiarity, and the knowledge that one of them is always with me (the gout is under control, but I am never even for a minute completely pain free) and the knowledge that I’m always at risk of the other.


Maria 10.14.08 at 9:21 pm

On the friendly familiarity of afflictions, I’ve detected some affection in Churchill’s description of the black dog.


Nic 10.14.08 at 9:40 pm

Emergency-medicine practitioners know that generic antiemetics are equally effective for the amelioration of acute migraine, do not provoke rebound migranes as triptans can, and are 1/10 the price. But of course there are no big marketing campaigns to tell you that!


Glen Tomkins 10.14.08 at 11:01 pm

Hopeless idealist… imagine that what we allow the drug companies to charge for any medication has anything to do with mechanism of action, production costs, proven efficacy or the severity of the condition that can be efficaciously treated. The price of medications is governed strictly by the Golden Rule, that he who has the gold makes the rules. Tom Womack above expresses the hope that the patents should start running out by the end of 1999, and that should, again merely hopefully, result in cheap generics soon thereafter. These hopes could be derailed if the patent-holders, using their gold, cadge an extension out of Congress, or if the oligopoly that is Big Pharma is gentlemanly (to each other, they don’t waste humanity or civility on the patient or taxpayer) enough to not compete with each other to bid down the price even after a triptan is out from under patent protection. I found out today, though these things no longer shock me, that the bromocriptine one of my patients needs, though it has been out from under patent since long before I was out from under med school, costs $300 a month.

Maybe a single payer in the US could rein this in. But until something does some reining in, it’s mob rule and club law that determines what meds cost.


Jonquil 10.14.08 at 11:02 pm

I agree that triptans changed my life for the better. Two years ago, when I traveled to London, Imitrex (sumatriptan) was available over the counter in Boots for some ridiculously low price — two pounds a pill, maybe?

In short, triptans are priced on what the market will bear, and the vendors have decided that we’ll pay $20.00 to get rid of a migraine. Which I will, but I have over 15 a month.

Isn’t the world beautiful right before a migraine, when colors and sounds and smells are exquisitely clear? About two minutes later I’m in bed with a pillow over my head.


Laura 10.14.08 at 11:25 pm

I knew the patent on Imitrex must be running out, because I just saw television ads here in the US for a new version – which is nothing more than the old Imitrex plus over-the-counter Aleve (naproxene sodium, something you can buy for $5 for 100 pills at any gas station). I pity anyone whose doctor is unethical enough to let them pay the jacked up price for this “new” drug, instead of the forthcoming generic plus a separate over-the-counter.

Me, I’m the pharmacutical companies’ dream customer. I burn through these drugs faster than the patents expire. Imitrex worked for a few years, then Maltax, now Relpax. I dread the day when the Relpax loses its efficacy and I have to find something else.


Jay 10.14.08 at 11:35 pm

Triptans were Prescription Only around here—I live in Germany—until about June or July this year, when they started to sell the Formigran brand OTC. It’s not as strong as other brands, but for me, it’ll do, most of the time. (Sometimes nothing’ll do, but that’s rare, luckily. Getting some liquids administered via IV at an emergency ward happend only twice in my life, so far.) The OTC stuff is moderately expensive, between the equivalent of $7 (online) and $12,50 (drug stores) for two units, which is the (strongly) recommended maximum dosage per attack anyways.

And yes, triptans are great. And no, Sontag’s well-written piece didn’t work out for me either.



mollymooly 10.14.08 at 11:49 pm

Why is this not the post entitled “The Name of This Band is Exploding Heads”?


Delicious Pundit 10.15.08 at 2:56 am

This would have been a great opportunity to slip in a reference to the Santa Anas, thereby making the post more Didionesque.


TrishB 10.15.08 at 3:29 am

For all those on triptans, remember to tell your doctor if you are also taking an anti-depressant. Triptans and SSRIs don’t play well together.


yoyo 10.15.08 at 5:24 am

I don’t use triptans. But i buy my meds from india, where they are almost free and don’t need a prescription.


Doug 10.15.08 at 6:35 am

mollymooly wins the thread!


Martin Wisse 10.15.08 at 6:48 am

I don’t hold with making an ally of migraine, but I will grant you that the first day after the enemy decamps is a Red Letter Day. Today I am so full of vim and vigour that it seems a shame to waste all that energy on work.

Oh boy, do I know this feeling. I’ve done some of my best work after finally getting rid of a persistent migraine or other headache. My theory is that you spent so much energy just holding your head together during a migraine, that once it’s gone the energy is still there waiting to be used.


gdr 10.15.08 at 9:53 am

I burn through these drugs faster than the patents expire. Imitrex worked for a few years, then Maltax, now Relpax. I dread the day when the Relpax loses its efficacy and I have to find something else.

Maybe you can record the adverts and keep the packaging for the old name-brand drug and then put the generic version in the fancy packaging, play back the adverts and so get the full effect without shelling out for the new drug?


Jay 10.15.08 at 12:48 pm

Does anyone have an idea how it is (chemically, medically) possible to develop a resistance to triptans? They’re serotonin receptor agonists, after all—or does our body/brain learn to know the difference between triptans and the “real” thing, over time? Or what is it?


Glen Tomkins 10.15.08 at 2:04 pm

Wheels within wheels

All of the neuro-transmitters, including serotonin, act in many different neural circuits. It’s not as if serotonin were even remotely exclusive to the circuits that make migraines or depression happen, even if we had any very precise idea what those circuits might be. All we know, and we only know it empirically, and not because the effects of serotonin enhancement or blockade were in any way predictable from any sort of detailed knowledge of the neural circuitry involved, is that these agents, at the right dose range, block the wrong circuits just enough, or encourage the right circuits just enough, to help most people with migraine or depression.

Yes, it is absolutely possible, to be expected, even, for the brain to adapt to pharmacologic intervention that floods the zone with pro- or anti-serotonin effect, by increasing its own effect in the opposite direction. Living systems auto-regulate to keep themselves in equilibrium, so, yes, auto-regulation to counter a medication is not unexpected, and actually observed with many classes of medication. If serotonin had only one action in the brain, you would be right, you would expect the body’s attempts to auto-regulate towards a healthy equlibrium would act with the medication to get back to the healthy state. But because serotinin has many actions, does many things besides the migraine or depression that we’re interested in, the body has evolved to maintain overall equlibrium of serotinin, so will tend to react to pharmacologic flooding of the zone with an equally non-specific counter-flooding in the opposite direction. This, unfortunately, will sometines make a medication lose efficacy over time.


Jay 10.15.08 at 3:18 pm

Glen, thank you! For explaining this succinctly and intelligibly, and for taking the time! :-)


Laura 10.15.08 at 3:32 pm

Yes, Glen, thank you for defending my honor against charges of being a dupe.

On a tangent, isn’t that counter-flooding response to the serotonin flood essentially the same reason MDMA (ecstacy) isn’t a very good regular hobby?


Maria 10.15.08 at 4:52 pm

Thank you Glen (and Jay). This is what I love about CT – you write a breezy little post and the next thing you know, our far cleverer contributors have done something helpful and beautiful with it.

And yes, Mollymooly is definitely the winner.


Jay 10.15.08 at 6:15 pm

Laura, I apologize for not expressing myself clearly enough, leaving room for misunderstandings. Of course I never doubted in any way that people develop a resistance to triptans. It’s only that I didn’t have a clue as to why that would be so, and I sincerely wanted to know.


Carrie K 10.15.08 at 8:12 pm

Scientific American had an interesting article on migraines in their August issue.

I live in fear that Maxalt MLT won’t work for me one of these days.


Katherine 10.15.08 at 10:45 pm

I think itwas gdr @ #18 suggesting that Laura was a dupe, not you Jay.


John Emerson 10.15.08 at 11:44 pm

Nietzsche spoke of illness in a philosophical way, as though it were a metaphor, but I he had debilitating headaches plus insomnia. And I think that he spoke of the time immediately after a bad episode as being his most creative time. So maybe Nietzsche’s generalizations about sickness and genius should be interpreted in terms of him and his specific disease.


Jay 10.16.08 at 12:12 am

Thanks Katherine, now I see. I was kind of wondering, but I didn’t want to rule it out… My writing and reading skills often need a day or two to fully recover from a migraine attack, and during that period I can muddle things up quite beautifully.


Jay 10.16.08 at 12:27 am

@John, could you direct me to some passages to that effect (“Nietzsche spoke of illness in a philosophical way, as though it were a metaphor”)?

While I was working on my Ph.D. thesis, I had to engage Nietzsche’s writings on rhetoric and figurative language at some point, and I smell something really interesting here. Some kind of reversed Sontag, actually.


Brett Bellmore 10.16.08 at 2:09 am

I get the fun “ocular” migraines; Don’t particularly hurt, I just go blind, and spend a half hour or so watching the kaleidoscope. If I understand right, it’s the exact same mechanism, just a slightly different part of the brain effected. On the bright side, I can see it coming with a few minutes warning, (My vision starts getting pixilated.) so I’ve got time to pull over to the side of the road. On the down side, I have to be careful how closely I look at brightly lit, sparkly objects, prolonged exposure will trigger an attack. (I’d never make it as a jeweler!)

Might be worth getting some triptans once the price drops, if the effect is fast enough that I could pop a pill, and stop the attack before I’m totally blind. Does it work that fast if you’ve got one right at hand when the attack starts?


Maria 10.16.08 at 4:56 am

It can work that fast, if you’ve got the pills that melt in your mouth. It seems a shame to miss the light show, though.


matt 10.16.08 at 1:03 pm

Also, the injections work w/in seconds- really great stuff. But, the case for carrying them around is bit big to fit in your pocket so you’d need a bag or purse or jacket or something, and, as noted, at least w/ my insurance company they make you pay the same amount for 2 injections (they come in sets of two) as for 9 pills, so I almost always use a pill, even if it will mean suffering for a half hour to an hour. (Unless you are _really_ afraid of needles there’ s no need to be afraid of the injections- it’s a little mechanism, just pops right in, you can’t hardly feel it, and you don’t see the needle until it’s all done. It’s easy to use but there is sometimes a bit of bleeding- small enough to stop, but enough to stain your clothes if you don’t watch for it.)


coco 10.17.08 at 6:54 am

ah, for me the triptans were a sort of devil’s bargain. every triptan i tried was effective but accompanied by a couple of hours of extreme pain and disorientation. so, with every migraine i had the option of either slogging 10+ hours with moderate-to-severe migraine pain or 2 hours of excruciating triptan pain. in most cases, it was less debilitating to just deal with the migraine.

medical marijuana ftw


David 10.17.08 at 8:51 pm

I am a headache physician and frequently come across patients who report that a drug that once worked now no longer does (tachyphylaxis). Sometimes I suspect that the patient’s headaches have actually worsened overall making the drug no longer effective. In cases where this doesn’t hold, often returning to an old drug that used to work is effective. The tolerance (or whatever change has produced the lack of effect) has now worn off and the old drug works again!

Also, we commonly use medications with different mechanisms of action (such as triptans + NSAIDS + anti-nauseants) together for better efficacy if one alone is not sufficient.


DHN 10.17.08 at 9:44 pm

The original question was why these drugs are so expensive. I’m kind of surprised that commenters on this site aren’t economically literate enough to see that there are two main answers:

1. The manufacturer has a monopoly (called a patent).

2. Third-party payment (health insurance) separates most consumers from the cost.

The price almost certainly will go down when the patent expires. There are lots of generic manufacturers that are not part of the “Big Pharma” club. Consider the plunging prices of drugs like Zocor (simvastatin) and Ambien (zolpidem since the patent expired. The only reasons the price wouldn’t go down are (a) if there is insufficient demand to justify capital investment necessary to manufacture and distribute the drug or (b) if the manufacturing process itself is too expensive. And if either of those is true, then the drug isn’t overpriced. But they probably aren’t true, or the manufacturer would not be putting out the new version that Laura describes.

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