What is the recommended dosing for sumatriptan (Imitrex) in the treatment of migraine?

Sumatriptan Dosing for Migraine

For oral sumatriptan, start with 50 mg or 100 mg at migraine onset, as these doses provide superior efficacy compared to 25 mg, with the 50 mg dose offering the best balance of effectiveness and tolerability. 1

Oral Dosing Recommendations

The FDA-approved oral dosing is 25 mg, 50 mg, or 100 mg, with doses of 50 mg and 100 mg providing greater effect than 25 mg. 1

• The 100 mg dose may not provide significantly greater effect than 50 mg but carries higher risk of adverse reactions 1
• If the migraine persists or returns after 2 hours, a second dose may be administered with at least 2 hours between doses 1
• Maximum daily dose is 200 mg in a 24-hour period 1
• Patient preference studies show 35% prefer 100 mg, 31% prefer 50 mg, and 25% prefer 25 mg, with efficacy and speed of action being the main reasons for preferring higher doses 2

Alternative Routes of Administration

Subcutaneous administration provides the fastest and most effective relief:

• 6 mg subcutaneous dose can be repeated after one hour, with maximum of 12 mg per 24 hours 3, 4
• Achieves 70-80% headache relief within 1 hour 3
• Injection site reactions occur in approximately 30% of patients 5, 4

Intranasal administration:

• 5-10 mg (one to two sprays) in one nostril, can be repeated after 2 hours 3, 4
• Maximum daily dose of 40 mg per day 3, 4

Treatment Strategy Algorithm

Before abandoning sumatriptan, patients should trial the medication for 2-3 headache episodes, as response can vary between attacks. 5, 4

If inadequate response after dose optimization:

1. Add an NSAID or acetaminophen to sumatriptan for combination therapy 5
2. Consider switching to another triptan (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, or zolmitriptan) 5
3. For severe nausea or vomiting, use a nonoral triptan with an antiemetic 5

Special Populations

In patients with mild to moderate hepatic impairment, maximum single dose should not exceed 50 mg. 1

Critical Contraindications

Sumatriptan is absolutely contraindicated in:

• Concurrent use with ergotamine, MAOIs, or within 24 hours of another triptan 3, 5, 4
• Hemiplegic or basilar migraine 3, 5, 4
• Coronary artery disease 3, 5, 4
• Pregnancy 3, 5, 4
• Impaired hepatic function (use lower doses if treatment deemed necessary) 3, 5, 4

Common Adverse Effects

Expected side effects include:

• Nausea, warmth, vomiting, vertigo, malaise, headache 3, 5
• Chest pressure and heaviness (occurs in 3-5% of patients) 5, 6
• Injection site reactions with subcutaneous route (approximately 30%) 5, 4

Important Pitfalls to Avoid

Medication-overuse headache prevention: limit acute migraine treatment to no more than twice per week. 7

Headache recurrence occurs in approximately 40% of patients within 24 hours of initial response, regardless of route of administration. 8, 9 This is related to sumatriptan's short half-life of approximately 2 hours and can be effectively treated with an additional dose 6

Do not administer during migraine aura—wait until headache phase begins. 6