II. Indications: General
- Migraine Abortive Treatment (adults and children age 12 years and older)
- Cluster Headache (off-label except for Sumatriptan)
- 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
- Children age <12 years
- 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
- Zolmitriptan (Zomig)
- Oral: 2.5 mg, 5 mg
- Oral disintegrating tablets (ZMT): 2.5 mg, 5 mg
- Intranasal: 2.5 mg or 5 mg per spray
VII. Dosing
- Indicated for Migraine Headaches in adults and children age 12 years and older
- Oral (standard or disintegrating ZMT)
- Initial: 1.25 to 2.5 mg orally (up to maximum single dose of 5 mg)
- May repeat dose every 2 hours as needed
- Maximum: 10 mg in 24 hours
- Intranasal
- Dose: 2.5 to 5 mg spray (single dose unit)
- Onset: 15 minutes (faster than oral preparations)
- May repeat dose every 2 hours as needed
- Maximum: 10 mg in 24 hours
- Moderate to severe hepatic Impairment
- Do NOT use disintegrating ZMT or intranasal formulations
- Reduce oral dosing to 1.25 mg/dose (maximum total of 2.5 mg in 24 hours)
VIII. Adverse Effects
- See Triptan Overdose
- 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
- 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
-
Cimetidine
- Limit Zolmitriptan individual total doses to 2.5 mg (5 mg in 24 hours)
- See absolute contraindications above
- Lithium
-
Selective Serotonin Reuptake Inhibitor (SSRI)
- Risk of Serotonin Syndrome when combined with SSRI, SNRI or MAO Inhibitors
XI. Management: Overdose or Toxicity
- See Triptan Overdose
Images: Related links to external sites (from Bing)
Related Studies
| zolmitriptan (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| ZOLMITRIPTAN 2.5 MG ODT | Generic | $4.43 each |
| ZOLMITRIPTAN 2.5 MG TABLET | Generic | $1.08 each |
| ZOLMITRIPTAN 5 MG NASAL SPRAY | Generic | $72.00 each |
| ZOLMITRIPTAN 5 MG ODT | Generic | $3.91 each |
| ZOLMITRIPTAN 5 MG TABLET | Generic | $1.46 each |
| zomig (on 11/23/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
| ZOMIG 5 MG NASAL SPRAY | Generic | $72.00 each |