Contraindications for Sumatriptan (Imitrex)
Sumatriptan is absolutely contraindicated in patients with ischemic coronary artery disease, history of stroke or TIA, uncontrolled hypertension, peripheral vascular disease, hemiplegic or basilar migraine, and concurrent use of MAO-A inhibitors or ergot-containing medications. 1
Cardiovascular Contraindications
Sumatriptan should not be used in patients with:
- Ischemic coronary artery disease (CAD), including:
- Angina pectoris
- History of myocardial infarction
- Documented silent ischemia
- Coronary artery vasospasm (including Prinzmetal's angina) 1
- Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders 1
- Peripheral vascular disease 1
- Uncontrolled hypertension 1, 2
These contraindications are based on sumatriptan's vasoconstrictive properties, which can potentially trigger serious cardiac events in susceptible individuals. Rare but serious cardiac adverse reactions, including acute myocardial infarction, have been reported within hours of sumatriptan administration, even in patients without known CAD 1, 3.
Neurological Contraindications
Sumatriptan must be avoided in patients with:
- History of stroke or transient ischemic attack (TIA) 1
- History of hemiplegic or basilar migraine 1, 2
These patients are at higher risk of stroke when taking sumatriptan. Cerebral hemorrhage, subarachnoid hemorrhage, and stroke have occurred in patients treated with 5-HT1 agonists like sumatriptan 1.
Drug Interaction Contraindications
Sumatriptan should not be used:
- Within 24 hours of ergotamine-containing medications, ergot-type medications (such as dihydroergotamine or methysergide), or another 5-HT1 agonist 1, 4
- Concurrently with MAO-A inhibitors or within 2 weeks of discontinuing an MAO-A inhibitor 1
The combination of sumatriptan with ergot derivatives can cause prolonged vasospastic reactions, as demonstrated in a case report of myocardial infarction in a premenopausal woman following combined use of sumatriptan and methysergide 4.
Other Contraindications
Additional contraindications include:
- Ischemic bowel disease 1
- Hypersensitivity to sumatriptan (angioedema and anaphylaxis have been reported) 1
- Severe hepatic impairment 1
Special Considerations
Serotonin Syndrome Risk
While concurrent use of sumatriptan with SSRIs or SNRIs is not absolutely contraindicated, caution is advised due to the potential risk of serotonin syndrome 1, 5. Symptoms may include:
- Mental status changes (agitation, hallucinations, coma)
- Autonomic instability (tachycardia, labile blood pressure, hyperthermia)
- Neuromuscular abnormalities (hyperreflexia, incoordination)
- Gastrointestinal symptoms (nausea, vomiting, diarrhea)
Medication Overuse Headache
Limiting triptan use to no more than 9 days per month is recommended to prevent medication overuse headache 6, 1.
Cardiovascular Risk Assessment
For patients with multiple cardiovascular risk factors but no evidence of CAD:
- Consider administering the first dose in a medically supervised setting
- Perform an ECG immediately following administration
- Consider periodic cardiovascular evaluation for long-term users 1
Clinical Implications
When considering sumatriptan for migraine treatment, it's important to recognize that while it's an effective second-line therapy for moderate to severe migraine attacks, its use must be carefully evaluated against these contraindications to prevent potentially serious adverse events 2, 6.
For patients with contraindications to sumatriptan, alternative treatments such as NSAIDs (ibuprofen, naproxen sodium, aspirin) should be considered as first-line therapy for acute migraine attacks 6.