How to Administer Sumatriptan
Sumatriptan should be administered at the onset of migraine symptoms using one of three routes: subcutaneous 6 mg (fastest, most effective), oral 50-100 mg (most commonly used), or intranasal 5-20 mg (alternative for nausea/vomiting), with route selection based on speed of relief needed and patient tolerance for adverse effects. 1
Route Selection Algorithm
Subcutaneous Administration - First Choice for Severe/Rapid Relief
- Dose: 6 mg subcutaneously at migraine onset 1
- May repeat once after 1 hour if needed; maximum 12 mg per 24 hours 1
- Provides pain relief in 70-80% of patients within 1 hour (fastest onset at 10 minutes) 2, 3
- Most effective route but highest adverse event rate (injection site reactions in ~30-40%, chest pressure in 3-5%) 4, 3
- Best for: severe attacks, patients with early vomiting, those requiring rapid relief 2
Oral Administration - First Choice for Most Patients
- Starting dose: 50 mg orally at migraine onset 5
- Alternative: 25 mg (better tolerated) or 100 mg (more effective but more adverse events) 1, 5
- May repeat every 2 hours if needed; maximum 200 mg per 24 hours 1
- Provides complete pain relief in 28% at 2 hours with 50 mg dose (vs 11% placebo) 3
- The 50 mg dose offers the best efficacy-to-tolerability ratio, though patients often prefer 100 mg 5
Intranasal Administration - For Nausea/Vomiting
- Dose: 5-20 mg (one to two sprays) in one nostril 1
- May repeat after 2 hours; maximum 40 mg per 24 hours 1
- The 20 mg dose is most effective (NNT 3.5) 3
- Best for: patients with significant nausea who cannot tolerate oral medication or refuse injections 2, 6
Critical Timing Considerations
- Administer at migraine onset, not during aura phase 6
- Taking medication when pain is still mild is more effective than waiting for moderate/severe pain 3
- Approximately 40% of responders experience headache recurrence within 24 hours, which can be treated with a repeat dose 6, 4
Absolute Contraindications
Do not administer sumatriptan if patient has: 1, 6
- Coronary artery disease, previous myocardial infarction, or Prinzmetal angina
- Hemiplegic or basilar migraine
- Uncontrolled hypertension
- Severe hepatic impairment (if using oral route, maximum 50 mg single dose for mild-moderate impairment) 7
- Used ergotamine or another triptan within 24 hours 1
- Current MAOI use 1
Drug Interaction Warning
Mandatory 24-hour washout period required between sumatriptan and dihydroergotamine (DHE) in either direction 8
Special Populations
Pregnancy
- Pregnancy Category C: use only if benefit justifies risk 7
- Associated with embryolethality and fetal abnormalities in animal studies 7, 9
Breastfeeding
Elderly
- Start at low end of dosing range 7
- Cardiovascular evaluation recommended before prescribing if other cardiac risk factors present 7
Pediatric
Common Adverse Effects to Counsel Patients About
- Cardiovascular sensations: chest pressure, heaviness, warmth (3-5% of patients) 10, 6
- Gastrointestinal: nausea, vomiting, dry mouth 10
- General: malaise, vertigo, neck/throat/jaw discomfort 10
- Injection site reactions with subcutaneous route (30-40%) 4
Medication Overuse Headache Risk
Limit use to no more than twice weekly to avoid medication overuse headache 10