How to Administer Sumatriptan for Migraine Treatment
Administer sumatriptan at the onset of migraine symptoms using one of three routes: subcutaneous 6 mg (fastest relief), oral 50-100 mg, or intranasal 5-20 mg, with route selection based on severity and need for rapid relief. 1
Route Selection Algorithm
For Moderate to Severe Migraine or Need for Rapid Relief
- Subcutaneous route is preferred: Give 6 mg subcutaneously at migraine onset 1
- This achieves headache relief in 70-80% of patients within 1 hour 2, 3
- May repeat once after 1 hour if needed, with maximum 12 mg per 24 hours 1
For Mild to Moderate Migraine
- Oral route: Give 50-100 mg at onset 4
- The 50 mg and 100 mg doses provide greater effect than 25 mg, though 100 mg may not be superior to 50 mg 4
- Achieves headache relief in 50-67% of patients within 2 hours 3
- May repeat after 2 hours if headache persists or returns, with maximum 200 mg per 24 hours 4
For Migraine with Nausea/Vomiting
- Intranasal route is preferred: Give 5-20 mg (20 mg is more effective) 1
- Onset of relief begins as early as 15 minutes with 20 mg dose 5
- May repeat after 2 hours, with maximum 40 mg per 24 hours 1
- Particularly useful when oral medication is precluded by vomiting 5
Critical Timing Considerations
- Administer at onset of headache phase, not during aura 2
- Allow adequate trial: patients should try sumatriptan for 2-3 headache episodes before abandoning therapy 6
- If inadequate response after dose optimization, combine with NSAID or acetaminophen, or switch to another triptan 6
Absolute Contraindications
Do not administer sumatriptan in patients with: 1, 7
- Coronary artery disease, previous myocardial infarction, or Prinzmetal angina
- Hemiplegic or basilar migraine
- Uncontrolled hypertension
- Recent use (within 24 hours) of ergotamine-containing medications or another triptan
- Current MAOI use
Mandatory Drug Interaction Precautions
- Require 24-hour washout period between sumatriptan and dihydroergotamine (DHE) in either direction 1
- Do not use within 24 hours of any other triptan 7
- Contraindicated with MAO-A inhibitors due to unpredictable elevations in bioavailability 8
Special Population Dosing
Hepatic Impairment
- Maximum single dose should not exceed 50 mg orally in mild to moderate hepatic impairment 4, 8
- Hepatic disease causes unpredictable elevations in oral sumatriptan bioavailability 8
Common Pitfalls to Avoid
- Medication overuse headache: Limit use to no more than twice weekly to avoid rebound headaches 7
- The safety of treating more than 4 headaches per 30-day period has not been established 4, 8
- Approximately 40% of patients experience headache recurrence within 24 hours, which can be effectively treated with a repeat dose 2, 3
Expected Adverse Effects to Counsel Patients About
- Cardiovascular sensations (chest pressure, heaviness, warmth) occur in 3-5% of patients but rarely indicate myocardial ischemia 1, 2
- Injection site reactions (minor pain, redness) occur in approximately 30-40% with subcutaneous administration 2, 3
- Intranasal administration commonly causes disturbance of taste (bad, bitter, or unpleasant) 5
- General effects include nausea, malaise, vertigo, and neck/throat/jaw discomfort 7
Rescue Strategy for Treatment Failure
If sumatriptan fails after appropriate dosing and adequate trial, consider switching to alternative triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, or zolmitriptan) as individual response varies 6