What is the recommended dosing for sumatriptan (Imitrex) in the treatment of migraines?

Sumatriptan Dosing for Migraines

The recommended oral dose of sumatriptan for migraine treatment is 25 mg, 50 mg, or 100 mg, with a maximum daily dose of 200 mg in a 24-hour period, and doses may be repeated after 2 hours if the migraine persists or returns. 1

Dosing by Route of Administration

Oral Administration

• Initial dose: 25 mg, 50 mg, or 100 mg 1
• Doses of 50 mg and 100 mg may provide greater effect than 25 mg, but 100 mg may not provide greater effect than 50 mg 1
• If migraine persists after 2 hours or returns after improvement, a second dose may be administered at least 2 hours after the first dose 1
• Maximum daily dose: 200 mg in a 24-hour period 1
• In patients with mild to moderate hepatic impairment, maximum single dose should not exceed 50 mg 1

Subcutaneous Administration

• Initial dose: 6 mg 2, 3
• May be repeated after one hour if needed 2, 3
• Maximum daily dose: 12 mg per 24 hours 2, 3

Intranasal Administration

• Initial dose: 5-10 mg (one to two sprays) in one nostril 2, 3
• May be repeated after 2 hours if needed 2, 3
• Maximum daily dose: 40 mg per day 2, 3

Efficacy Considerations

• Patient preference studies show that 35% of patients prefer 100 mg, 31% prefer 50 mg, and 25% prefer 25 mg 4
• Higher doses (50 mg and 100 mg) are more effective than 25 mg for headache relief at 2,3, and 4 hours after dosing 4
• The 50 mg dose likely has the best effectiveness-to-tolerability ratio, though some patients clearly prefer a higher dose 4
• Patients should try a medication for 2-3 headache episodes before abandoning that line of therapy 5

Combination Therapy

• If adequate dose of sumatriptan still does not provide sufficient pain relief, consider combining with an NSAID or acetaminophen 5
• If inadequate response after dose optimization, consider switching to another triptan (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, or zolmitriptan) 5

Important Contraindications

• Sumatriptan should not be used with:
  • Ergotamine or ergot-type medications 2, 3, 5
  • MAOIs 2, 3, 5
  • Within 24 hours of another triptan 2, 3, 5
• Contraindicated in patients with:
  • Hemiplegic or basilar migraine 2, 3, 5
  • Pregnancy 2, 3, 5
  • Impaired hepatic function (dose adjustment required) 2, 3, 5, 1
  • Coronary artery disease 2, 3, 5

Common Adverse Effects

• Oral administration: nausea, vomiting, malaise, fatigue, dizziness 2, 5, 6
• Subcutaneous administration: injection site reactions (approximately 30% of patients), chest pressure and heaviness 2, 5, 6
• Chest symptoms are reported in 3-5% of patients but have been associated with myocardial ischemia only in rare isolated cases 6

Clinical Pearls

• Approximately 40% of patients who initially respond to oral or subcutaneous sumatriptan experience recurrence of their headache usually within 24 hours, which can be effectively treated by a further dose 6
• The median time to recurrence increases with dose, from 8.5 hours with 25 mg to 11.8 hours with 100 mg 4
• Sumatriptan should not be given during the migraine aura 6
• The safety of treating an average of more than 4 headaches in a 30-day period has not been established 1
• Consider using a nonoral triptan and an antiemetic in people having severe nausea or vomiting 5