II. Indications: General
-
Migraine Abortive Treatment (adults)
- Intranasal form has been used off-label for age >8 years
- Cluster Headache (subcutaneous form)
- Controversial cohorts in whom Triptan use is now thought safe (Cardiovascular Risk Factors)
- Controlled Diabetes Mellitus
- Controlled Hypertension
- Controlled Hyperlipidemia
- Postmenopausal women
- Men over age 40 years
III. Contraindications
- Severe hepatic Impairment
- Coronary Artery Disease
- Prinzmetal's Angina
- Uncontrolled Hypertension
- Basilar Artery Migraine
- Familial Hemiplegic Migraine
- Ischemic Cerebrovascular Accident
- Pregnancy
- Concurrent Medication use (absolute contraindications)
- MAO Inhibitor use
- Ergotamine use in prior 24 hours
IV. Mechanism
- Serotonergic 5-HT1 receptor Agonists
- Inhibits sensory dural nerve fiber neuropeptide release
- Intracranial extracerebral artery Vasoconstriction
- Mediated by Triptan direct effect on cerebrovascular Smooth Muscle
V. Precautions
- Screen for cardiovascular disease before use!
- Limit to no more than twice weekly
VI. Medications
- Sumatriptan (Imitrex)
- Oral 25 mg, 50 mg, 100 mg
- Generic dosing may be as low as $3/dose
- Intranasal forms
- Intranasal Imitrex: 5 mg, 20 mg (box of 6)
- Intranasal Tosymra: 10 mg
- Intranasal Onzetra Xsail: 11 mg powder
- Even generic dosing approaches $100/dose
- Subcutaneous Injections
- Subcutaneous Imitrex Injection: 6 mg prefilled syringe cartridges (box of 4)
- Subcutaneous Zembrace SymTouch 3 mg autoinjector
- Oral 25 mg, 50 mg, 100 mg
- Treximet (combination with Naproxen)
- Zecurity patch (listed for historical reasons only)
- Removed from market 2016 due to serious adverse effects including burns
- http://www.fda.gov/Drugs/DrugSafety/ucm504588.htm
VII. Dosing
- Limit to use in adults
- Intranasal form has been used off-label for age >8 years
- Subcutaneous Sumatriptan
- Initial: 6 mg SC
- May repeat in 1 hour if no effect with first dose
- Doses of 1-5 mg may be used if 6 mg is not tolerated
- If Headache returns, may switch to oral tablets, giving 25 mg every 2 hours (max 100 mg in 24 hours)
- Maximum: 12 mg/day
- Do NOT give IM or IV (use only SQ)
- Initial: 6 mg SC
- Oral Sumatriptan
- Dose 25 to 100 mg orally every 2 hours as needed
- Start at 50 to 100 mg for first oral dose for best efficacy in young adult without contraindications
- Maximum: 200 mg in 24 hours
- Adjust for hepatic Impairment
- Mild to moderate hepatic Impairment: Limit maximum dose to 50 mg
- Severe hepatic Impairment: Avoid oral Sumatriptan
- Dose 25 to 100 mg orally every 2 hours as needed
- Oral Treximet
- Adults
- Take 1 tablet (85/500 mg) orally at Migraine onset
- May repeat once in 2 hours
- Maximum: 2 tabs in 24 hours
- Limit to one 10/60 mg in mild to moderate hepatic Impairment (and avoid in severe hepatic Impairment)
- Child age >12 years
- Give 1 tablet (10/60 mg) orally at Migraine onset
- Maximum: 1 tablet (85/500 mg) in 24 hours
- Adults
- Intranasal Sumatriptan
- Initial: 5, 10 or 20 mg intranasal
- Dose responsive (20 mg most effective)
- Repeat after 2 hours as needed
- Maximum: 40 mg in 24 hours
- Safety of use in over 4 Headaches per month not known
- Although FDA approved only for adults, Intranasal form has been used off-label for age >8 years
- Initial: 5, 10 or 20 mg intranasal
VIII. Adverse Effects
- See Triptan Overdose
- Injection (e.g. Sumatriptan)
- Intranasal preparations
- Dysgeusia (Terrible taste)
- Vasospasm
- Generally benign in low risk populations
- Avoid in Coronary Artery Disease, Cerebrovascular Disease, Peripheral Arterial Disease
- Also avoid in hemiplegic Migraine or basilar Migraine
-
Medication Overuse Headaches
- Highest risk with >10 doses per month
- Limit to two doses weekly
IX. Safety
- Unknown safety in Lactation
- Pregnancy Category C (most Triptans, but generally avoided in pregnancy)
- See Migraine Medications in Pregnancy
- Not recommended for routine use in pregnancy
- Avoid Treximet in pregnancy overall (contains Naproxen)
- Consult obstetrics before use
- May be considered if Migraines are uncontrolled, debilitating
- If used, Sumatriptan has the longest safety data
- Adverse effects in pregnancy
- Avoid in first trimester (fetal malformations and adverse pregnancy outcomes)
- Risk of uterine atony and peripartum Hemorrhage (but may be considered in debilitating Headache)
- Associated with hyperactivity and emotionality at age 3 in exposed children (AHRQ)
- References
X. Drug Interactions
- See absolute contraindications above
- Lithium
-
Selective Serotonin Reuptake Inhibitor (SSRI)
- Risk of Serotonin Syndrome when combined with SSRI, SNRI or MAO Inhibitors
XI. Efficacy: Sumatriptan
- Efficacy dependent on mode of drug delivery
- Subcutaneous effective in 80% of patients
- Intranasal effective in 70% of patients
- Oral effective in 60% of patients
- Oral form does not prevent Migraine recurrence
XII. Management: Overdose or Toxicity
- See Triptan Overdose
XIII. Resources
XIV. References
- Hamilton (2020) Tarascon Pocket Pharmacopoeia
- Jamieson (2002) Am J Med 112:138 [PubMed]
- Ahn (2005) Pain 115(1-2):1-4 +PMID: 15836963 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
| sumatriptan (on 10/19/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| SUMATRIPTAN 20 MG NASAL SPRAY | Generic | $19.13 each |
| SUMATRIPTAN 4 MG/0.5 ML INJECT | Generic | $132.25 per ml |
| SUMATRIPTAN 5 MG NASAL SPRAY | Generic | $36.07 each |
| SUMATRIPTAN 6 MG/0.5 ML AUTOINJ | Generic | $65.60 per ml |
| SUMATRIPTAN 6 MG/0.5 ML CART | Generic | $113.31 per ml |
| SUMATRIPTAN 6 MG/0.5 ML INJECT | Generic | $65.02 per ml |
| SUMATRIPTAN 6 MG/0.5 ML VIAL | Generic | $16.71 per ml |
| SUMATRIPTAN SUCC 100 MG TABLET | Generic | $0.50 each |
| SUMATRIPTAN SUCC 25 MG TABLET | Generic | $0.60 each |
| SUMATRIPTAN SUCC 50 MG TABLET | Generic | $0.43 each |
| SUMATRIPTAN-NAPROXEN 85-500 MG | Generic | $26.51 each |
| imitrex (on 1/1/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| IMITREX 100 MG TABLET | Generic | $0.50 each |
| IMITREX 20 MG NASAL SPRAY | Generic | $19.13 each |
| IMITREX 5 MG NASAL SPRAY | Generic | $36.07 each |
| IMITREX 50 MG TABLET | Generic | $0.43 each |
| IMITREX 6 MG/0.5 ML CARTRIDGES | Generic | $113.31 per ml |