Should sumatriptan (Imitrex) be held before surgery?

Perioperative Management of Sumatriptan (Imitrex)

Sumatriptan should be taken preoperatively but held on the day of surgery. 1

Rationale for Recommendation

The Society for Perioperative Assessment and Quality Improvement (SPAQI) provides clear guidance on triptan medications in the perioperative period. Triptans, including sumatriptan, are serotonin 5-HT1B/1D receptor agonists used for migraine treatment that require specific perioperative management due to potential drug interactions with anesthetic medications.

Mechanism of Action and Concerns

Sumatriptan works by:

• Acting as a selective agonist at vascular serotonin (5-HT1) receptor subtypes
• Causing vasoconstriction of cranial blood vessels
• Potentially interacting with other perioperative medications

The primary concerns with perioperative sumatriptan use include:

1. Theoretical risk of serotonin syndrome when combined with certain anesthetic medications 1
2. Potential drug-drug interactions through metabolic pathways (monoamine oxidase A, CYP3A4, CYP2D6, and CYP1A2) 1
3. Possible cardiovascular effects, including coronary artery vasospasm 2

Specific Recommendations

Preoperative Management

• Continue sumatriptan preoperatively but hold on the day of surgery 1
• No need for extended preoperative discontinuation (unlike ergotamine, which requires holding for at least 2 days) 1

Risk Considerations

• Patients with cardiovascular risk factors require special attention as sumatriptan may cause:
  • Coronary artery vasospasm (Prinzmetal's angina) 2
  • Chest, throat, neck, and jaw pain/tightness/pressure 2
  • Potential arrhythmias in susceptible patients 2

Postoperative Management

• May be resumed 24 hours after surgery for low bleeding risk procedures 3
• For high bleeding risk procedures, consider resuming 48-72 hours postoperatively 3

Special Situations

Migraine Management During Perioperative Period

• For patients experiencing acute migraine preoperatively, alternative treatments should be considered on the day of surgery
• For patients with history of severe postoperative nausea and vomiting with migraine history, discuss with anesthesia team about alternative antiemetic strategies

Contraindications

Sumatriptan is absolutely contraindicated in patients with:

• Ischemic or vasospastic coronary artery disease
• Uncontrolled hypertension
• History of stroke or TIA
• Wolff-Parkinson-White syndrome or other cardiac conduction disorders 2

Clinical Pearls

• Unlike many medications that require extended perioperative discontinuation, sumatriptan only needs to be held on the day of surgery
• There have been isolated case reports of successful use of sumatriptan perioperatively to treat and prevent migraine attacks 4, but these do not override the consensus recommendations
• The risk of serotonin syndrome is relatively low but increases when combined with other serotonergic medications commonly used perioperatively 1, 2
• Patients should be informed about the plan for perioperative management of their migraine medications, including when to resume sumatriptan postoperatively

Following these evidence-based recommendations will help minimize perioperative risks while maintaining appropriate migraine management for patients taking sumatriptan.