Intranasal Sumatriptan for Cluster Headache
Direct Recommendation
Intranasal sumatriptan 20 mg is an effective second-line acute treatment for cluster headache attacks, particularly when subcutaneous sumatriptan is not tolerated or practical, though it is less effective than the subcutaneous formulation. 1, 2, 3
Evidence-Based Dosing and Administration
Recommended Dosage
- Administer 20 mg intranasal sumatriptan (one spray in one nostril) at the onset of a cluster headache attack 3
- The medication achieves headache response (reduction from severe/moderate pain to mild/none) in 57% of patients at 30 minutes, compared to 26% with placebo 3
- Pain-free rates at 30 minutes are 47% with intranasal sumatriptan versus 18% with placebo 3
Important Efficacy Considerations
- Intranasal sumatriptan is most effective for attacks lasting at least 45 minutes duration 3
- The intranasal formulation is significantly less effective than subcutaneous sumatriptan 6 mg, which achieves 74-75% response rates within 15 minutes 1, 2, 4
- If headache recurs (which occurs in approximately 40% of responders within 24 hours), a second dose can be administered 5, 6
Treatment Algorithm for Acute Cluster Headache
First-Line Options (Choose One)
- Subcutaneous sumatriptan 6 mg - fastest and most effective (70-82% efficacy within 15 minutes) 1, 2, 4
- 100% oxygen at 12 L/min for 15 minutes - equally effective as first-line, no cardiovascular contraindications 1, 2, 4
Second-Line Options (When First-Line Not Suitable)
- Intranasal sumatriptan 20 mg - when subcutaneous route poorly tolerated or impractical 3, 7
- Intranasal zolmitriptan 10 mg - alternative triptan option 1, 2
Critical Contraindications
Do not use intranasal sumatriptan in patients with: 5
- Ischemic heart disease or previous myocardial infarction
- Vasospastic coronary disease (including Prinzmetal angina)
- Uncontrolled hypertension
- Other significant cardiovascular disease
- Concurrent use with ergotamine derivatives or other vasoconstrictive agents
Common Pitfalls to Avoid
Timing and Formulation Errors
- Do not confuse acute treatment with prophylactic treatment - intranasal sumatriptan treats individual attacks, not prevention 1, 2
- Do not administer during the aura phase - wait until headache pain begins 8
- Do not use intranasal sumatriptan as first-line when subcutaneous formulation is available and tolerated - the subcutaneous route is significantly more effective 4
Dosing Mistakes
- Do not exceed recommended dosing frequency - allow at least 24 hours between treated attacks in clinical trials 3
- Do not use intranasal sumatriptan for attacks shorter than 45 minutes - efficacy data specifically supports use in longer-duration attacks 3
Drug Interactions
- Do not combine with ergotamine derivatives - this is an absolute contraindication due to additive vasoconstrictive effects 5, 8
- Do not use concurrently with other triptans - allow adequate washout period 5
Adverse Effects Profile
Intranasal sumatriptan is generally well tolerated with transient side effects: 3
- No serious adverse events reported in controlled trials 3
- Mild chest symptoms (tightness/pressure) occur in 3-5% of patients but rarely indicate myocardial ischemia 8, 6
- Local nasal irritation may occur with intranasal formulation 3
- Better tolerability profile than subcutaneous formulation (no injection site reactions) 7
Clinical Context and Patient Selection
Consider intranasal sumatriptan specifically for patients who: 7
- Experience poor tolerability with subcutaneous sumatriptan (injection site reactions, systemic side effects)
- Find subcutaneous injections impractical or unacceptable
- Cannot access oxygen therapy quickly during attacks
- Have attacks lasting at least 45 minutes 3
The intranasal formulation offers advantages of convenience and better tolerability compared to subcutaneous administration, though at the cost of reduced efficacy and slower onset of action 7, 4