What are the contraindications for sumatriptan (Imitrex)?

Contraindications of Sumatriptan (Imitrex)

Sumatriptan is contraindicated in patients with ischemic coronary artery disease, history of stroke or TIA, uncontrolled hypertension, and several other specific conditions that increase the risk of serious adverse events. 1

Absolute Contraindications

• Cardiovascular conditions:

  • Ischemic coronary artery disease (including angina pectoris, history of myocardial infarction, or documented silent ischemia) 1
  • Coronary artery vasospasm, including Prinzmetal's angina 1, 2
  • Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders 1
  • Peripheral vascular disease 1
  • Uncontrolled hypertension 1, 3

• Cerebrovascular conditions:

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

• Gastrointestinal 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, 3
  • Recent use (within 24 hours) of another 5-HT1 agonist 1
  • Concurrent administration of a monoamine oxidase (MAO)-A inhibitor or recent (within 2 weeks) use of an MAO-A inhibitor 1

• Other contraindications:

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

Special Precautions and Warnings

• Cardiovascular risk:

  • For patients with multiple cardiovascular risk factors but no evidence of CAD, consider administering the first dose in a medically supervised setting 1
  • Monitor for arrhythmias, including life-threatening ventricular tachycardia and ventricular fibrillation 1

• Cerebrovascular events:

  • Risk of cerebral hemorrhage, subarachnoid hemorrhage, and stroke 1
  • Before treating patients not previously diagnosed with migraine or those with atypical symptoms, exclude other potentially serious neurological conditions 1

• Other vasospastic reactions:

  • May cause non-coronary vasospastic reactions (peripheral vascular ischemia, gastrointestinal vascular ischemia, splenic infarction, Raynaud's syndrome) 1
  • Reports of transient and permanent blindness and significant partial vision loss 1

• Drug interactions and adverse effects:

  • Risk of serotonin syndrome when co-administered with SSRIs, SNRIs, TCAs, and MAO inhibitors 1
  • Medication overuse headache with frequent use (10 or more days per month) 1
  • Significant elevation in blood pressure, including hypertensive crisis 1
  • Risk of seizures, especially in patients with history of epilepsy or conditions associated with lowered seizure threshold 1

Special Populations

• Pregnancy:

  • Should be used only under strict specialist supervision during pregnancy due to limited safety data 4
  • Paracetamol (acetaminophen) is the preferred first-line medication for acute treatment of migraine in pregnancy 4

• Breastfeeding:

  • Considered relatively safe during breastfeeding 4

• Children and adolescents:

  • Multiple triptans including sumatriptan have been approved for adolescents aged 12-17 years 4
  • Nasal spray formulations of sumatriptan may be most effective in adolescents 4

Clinical Considerations

• Chest symptoms (tightness and pressure) occur in 3-5% of sumatriptan recipients 2, 5
• Approximately 40% of patients who initially respond to sumatriptan may experience recurrence of their headache, usually within 24 hours 2, 6
• Most adverse events are transient, with the most common being nausea, vomiting, malaise, fatigue, and dizziness 2
• Injection site reactions occur in approximately 30-40% of patients receiving subcutaneous sumatriptan 6

Always perform a thorough cardiovascular evaluation in triptan-naïve patients who have multiple cardiovascular risk factors before prescribing sumatriptan, and consider periodic cardiovascular evaluation in long-term users 1.