Sumatriptan Dosing for Acute Migraine Treatment
For acute migraine attacks, start with sumatriptan 50 mg orally, which can be repeated once after 2 hours if needed, with a maximum daily dose of 200 mg per 24 hours. 1
Initial Dose Selection
The 50 mg oral dose provides the optimal balance between efficacy and tolerability for most patients, achieving headache relief in approximately 58-67% of patients within 2 hours while maintaining a side effect profile similar to placebo 2, 3
The 100 mg dose may provide greater efficacy than 25 mg but does not consistently outperform 50 mg, while carrying a higher risk of adverse events 1, 3
The 25 mg dose is less effective than both 50 mg and 100 mg doses and should be reserved for patients with hepatic impairment (maximum 50 mg single dose in this population) 1, 3
Dosing Intervals and Repeat Dosing
If the migraine has not resolved by 2 hours or returns after initial improvement, administer a second dose at least 2 hours after the first dose 1
Among patients who achieve initial headache relief, approximately 40% will experience recurrence within 24 hours, but the majority respond well to a second dose 4, 5
The maximum daily dose is 200 mg in a 24-hour period 1
Trial Period Before Switching
Patients should trial sumatriptan for 2-3 separate migraine episodes before determining it ineffective, as response can vary between attacks 6, 7
If inadequate response occurs after appropriate dose optimization across multiple attacks, switch to a different triptan (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, or zolmitriptan) 7
Frequency Limitations to Prevent Medication Overuse
Limit sumatriptan use to treating no more than 4 headaches per 30-day period to avoid medication-overuse headache 1
The safety of treating more than 4 headaches in a 30-day period has not been established 1
Alternative Routes for Severe Presentations
For severe migraines or when significant nausea/vomiting are present, use subcutaneous sumatriptan 6 mg, which achieves peak blood concentration in approximately 15 minutes and provides relief in 70-82% of patients within 1 hour 6, 7
Subcutaneous dosing can be repeated after 1 hour, with a maximum daily dose of 12 mg per 24 hours 7
Intranasal sumatriptan 5-10 mg (one to two sprays) in one nostril can be repeated after 2 hours, with a maximum daily dose of 40 mg 7
Combination Therapy for Insufficient Response
If adequate doses of sumatriptan alone provide insufficient pain relief, add an NSAID or acetaminophen to the triptan rather than increasing the triptan dose further 7
This combination approach is recommended by current guidelines when monotherapy fails 7
Critical Contraindications
Sumatriptan is absolutely contraindicated in patients with ischemic heart disease, vasospastic coronary disease (including Prinzmetal angina), uncontrolled hypertension, or other significant cardiovascular disease 6
Do not use within 24 hours of ergotamine derivatives or another triptan, or within 14 days of MAOI use 7
Contraindicated in hemiplegic or basilar migraine, pregnancy, and impaired hepatic function 7
Common Adverse Effects
Expect minor, transient side effects including nausea, warmth, malaise, and chest pressure/heaviness in approximately 14% more patients than placebo with the 100 mg dose 8
Subcutaneous administration causes injection site reactions in approximately 30-40% of patients, though this is markedly reduced with auto-injector use 7, 5
Chest symptoms (tightness and pressure) occur in 3-5% of patients but have rarely been associated with myocardial ischemia 5