What is the dose of sumatriptan for acute migraines?

Sumatriptan Dosing for Acute Migraines

The recommended dose of sumatriptan for acute migraine treatment is 25 mg, 50 mg, or 100 mg orally, with 50 mg often providing the optimal balance between efficacy and tolerability. 1

Dosing Guidelines

Oral Sumatriptan Dosing

• Starting dose options:
  • 25 mg, 50 mg, or 100 mg orally
  • 50 mg is often the preferred starting dose due to balance of efficacy and tolerability 1, 2
  • 100 mg may provide greater effect than 25 mg, but may not be superior to 50 mg 1

Maximum Dosing

• If migraine has not resolved after 2 hours, a second dose may be administered
• At least 2 hours must elapse between doses
• Maximum daily dose: 200 mg in a 24-hour period 1

Special Populations

• Hepatic impairment: Maximum single dose should not exceed 50 mg in patients with mild to moderate hepatic impairment 1

Alternative Administration Routes

• Subcutaneous: 6 mg, may be repeated after 1 hour; maximum 12 mg per 24 hours 3
• Intranasal: 5-10 mg (1-2 sprays) in one nostril; may be repeated after 2 hours; maximum 40 mg per day 3

Efficacy Considerations

• Higher doses (50 mg and 100 mg) are significantly more likely to provide headache relief at 2,3, and 4 hours compared to 25 mg 4, 2
• Patient preference studies show:
  • 35% of patients prefer 100 mg
  • 31% prefer 50 mg
  • 25% prefer 25 mg 4
• The 50 mg dose likely has the best effectiveness-to-tolerability ratio 4

Safety and Adverse Effects

• Adverse event incidence increases with dose:
  • 25 mg: 19%
  • 50 mg: 21%
  • 100 mg: 30% 4
• Common adverse effects include nausea, vomiting, malaise, fatigue, and dizziness 5
• Chest symptoms (tightness/pressure) occur in 3-5% of patients 5

Important Contraindications

• Ergotamine use
• MAOIs
• Use within 24 hours of another triptan
• Hemiplegic or basilar migraine
• Pregnancy
• Impaired hepatic function
• Coronary artery disease 3

Clinical Decision Algorithm

1. For most patients: Start with 50 mg oral sumatriptan
2. If inadequate response: Consider increasing to 100 mg for subsequent attacks
3. If good efficacy but side effects occur: Consider decreasing to 25 mg
4. If oral medication is not tolerated or rapid relief is needed: Consider subcutaneous (6 mg) or intranasal (5-10 mg) formulations
5. For patients with hepatic impairment: Do not exceed 50 mg per dose

Treatment Pearls

• Allow patients to try a medication for 2-3 headache episodes before abandoning that therapy 3
• If one triptan is ineffective, a different triptan should be tried 3
• Approximately 40% of patients may experience headache recurrence within 24 hours, but most respond well to a second dose 5

Remember that sumatriptan remains effective and well-tolerated over several months of use for acute migraine treatment 5.