When is Imitrex (sumatriptan) contraindicated?

Contraindications for Imitrex (Sumatriptan)

Imitrex (sumatriptan) should not be given to patients with ischemic coronary artery disease, vasospastic coronary disease, uncontrolled hypertension, or other significant cardiovascular disease due to the risk of serious cardiac events including myocardial infarction. 1, 2

Absolute Contraindications

• Cardiovascular conditions:

  • Ischemic coronary artery disease (angina pectoris, history of myocardial infarction, documented silent ischemia) 1
  • Coronary artery vasospasm, including Prinzmetal's angina 1
  • Peripheral vascular disease 1
  • Uncontrolled hypertension 2, 1
  • Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders 1

• Cerebrovascular conditions:

  • History of stroke or transient ischemic attack (TIA) 1
  • History of hemiplegic or basilar migraine 1

• Other vascular conditions:

  • Ischemic bowel disease 1

• Medication interactions:

  • Recent use (within 24 hours) of ergotamine-containing medications or other ergot-type medications (such as dihydroergotamine or methysergide) 1, 2
  • Recent use (within 24 hours) of another triptan medication 1
  • Concurrent use or recent use (within 2 weeks) of MAO-A inhibitors 1

• Other contraindications:

  • Hypersensitivity to sumatriptan (risk of angioedema and anaphylaxis) 1
  • Severe hepatic impairment 1

Special Precautions and Relative Contraindications

• Serotonin syndrome risk: Caution when using with SSRIs, SNRIs, or TCAs due to risk of serotonin syndrome 1

• Seizure risk: Use with caution in patients with history of epilepsy or conditions associated with lowered seizure threshold 1

• Pregnancy considerations: Sumatriptan has oxytocic properties that may affect pregnancy 2

• Medication overuse headache: Avoid frequent use (10 or more days per month) as it may lead to medication overuse headache 1

Cardiovascular Risk Assessment

For patients with multiple cardiovascular risk factors but no established CAD:

• Consider administering the first dose in a medically supervised setting 1
• Perform an ECG immediately following administration 1
• Consider periodic cardiovascular evaluation for long-term users 1

Clinical Implications

The risk of severe cardiovascular adverse events after triptan use is estimated at 1:100,000 treated attacks 3. While rare, these events highlight the importance of careful patient selection before prescribing Imitrex.

Patients experiencing symptoms or signs suggestive of non-coronary vasospasm reactions (such as peripheral vascular ischemia, gastrointestinal vascular ischemia, Raynaud's syndrome) should be evaluated for vasospastic reactions before receiving additional doses 1.

Monitoring Recommendations

• Monitor blood pressure in all patients treated with sumatriptan 1
• Watch for signs of serotonin syndrome when combining with other serotonergic medications 1
• Be alert for potential medication overuse headache with frequent use 1

Remember that proper patient selection is critical for safe use of Imitrex, as even with careful screening, serious adverse events can occur in patients taking their first dose 3.