When is sumatriptan (Imitrex) used for migraine treatment?

When to Use Sumatriptan for Migraine Treatment

Sumatriptan should be used as second-line therapy for moderate to severe migraine attacks when over-the-counter NSAIDs (aspirin, ibuprofen, or diclofenac) provide inadequate relief. 1

Stepped Care Algorithm for Sumatriptan Use

First-Line Treatment (Try These First)

• Begin with NSAIDs (aspirin, ibuprofen, or diclofenac potassium) for all migraine attacks 1
• Reserve paracetamol only for patients intolerant of NSAIDs 1

Second-Line Treatment (When to Escalate to Sumatriptan)

Offer sumatriptan when:

• Over-the-counter analgesics provide inadequate headache relief after 2-3 migraine episodes 1
• Migraine attacks are moderate to severe in intensity 1, 2
• A clear diagnosis of migraine with or without aura has been established 2

Optimal Timing for Administration

• Take sumatriptan early in the attack when headache is still mild for maximum effectiveness 1
• Do NOT use during the aura phase - there is no evidence supporting efficacy at this stage 1
• If no response occurs to the first treated attack, reconsider the diagnosis before treating subsequent attacks 2

Route Selection Based on Clinical Presentation

Oral Sumatriptan (Standard Route)

• Dosing: 50-100 mg at onset; may repeat after 2 hours if needed (maximum 200 mg/24 hours) 2
• Use for typical migraine attacks without severe nausea or vomiting 1
• 50-67% of patients achieve headache relief at 2 hours 3, 4

Subcutaneous Sumatriptan (Rescue Therapy)

Use subcutaneous sumatriptan 6 mg when: 1

• All oral triptans have failed
• Patient rapidly reaches peak headache intensity
• Severe vomiting prevents oral medication
• Fastest relief is needed (70-82% effective within 1 hour) 1, 4

Intranasal Sumatriptan

• Use when significant nausea or vomiting is present but subcutaneous route is not preferred 1, 5
• Dosing: 5-20 mg per nostril 5

Critical Contraindications (Do Not Use If Present)

• Ischemic heart disease or coronary vasospasm 1, 6
• Previous myocardial infarction 6, 4
• Uncontrolled hypertension 1, 6, 4
• Basilar or hemiplegic migraine 7
• Concurrent use with ergotamines or MAO inhibitors 1, 6

Managing Treatment Failure

If One Triptan Fails

• Try a different triptan - failure of one does not predict failure of others 1
• Allow adequate trial period: no response in at least 3 consecutive attacks before abandoning 1

For Headache Recurrence (40% of patients)

• May repeat sumatriptan dose after 2 hours 2
• Combine with fast-acting NSAIDs (naproxen sodium, ibuprofen lysine, or diclofenac potassium) to prevent relapse 1
• Be aware that repeating treatment increases risk of medication-overuse headache 1

Preventing Medication-Overuse Headache

Limit sumatriptan use to no more than 2 days per week 5, 8, 7

• Using acute medications more than twice weekly can lead to daily headaches 1, 5
• Maximum of 4 headaches treated per 30-day period 2
• If needing treatment more frequently, initiate preventive therapy instead 5, 8

When Sumatriptan is NOT Indicated

• Prevention of migraine attacks (not a prophylactic agent) 2
• Cluster headache (not FDA-approved for this indication, though subcutaneous form shows efficacy) 2, 4
• Tension-type headache or other non-migraine headaches 2

Special Populations

Hepatic Impairment

• Maximum single dose should not exceed 50 mg in mild to moderate hepatic impairment 2

Combination with Antiemetics

• Add metoclopramide 10 mg or domperidone for patients with significant nausea 1, 5
• Antiemetics provide synergistic analgesia beyond treating nausea alone 5