Subcutaneous Medications for Migraine Treatment
Subcutaneous sumatriptan 6 mg is the most effective and rapidly acting subcutaneous medication for acute migraine attacks, providing pain relief in 70-82% of patients within 15 minutes and complete pain relief in approximately 59% of patients by 2 hours. 1, 2
Primary Subcutaneous Option: Sumatriptan
For acute migraine treatment requiring rapid relief, subcutaneous sumatriptan 6 mg is the gold standard subcutaneous medication. 1, 2
- Subcutaneous sumatriptan reaches peak blood concentrations faster than any other migraine-specific medication (approximately 15 minutes) 1
- It achieves the highest efficacy rates among all routes of triptan administration, with 59% of patients achieving complete pain freedom by 2 hours compared to 15% with placebo (NNT 2.3) 3, 4
- The 4 mg subcutaneous dose is also available and nearly as effective as 6 mg, with slightly lower adverse event rates 1, 4
When to Choose Subcutaneous Sumatriptan
- Patients with severe migraine attacks requiring the most rapid relief 2
- Patients with significant nausea and/or vomiting who cannot tolerate oral medications 1, 2
- Patients who rapidly reach peak headache intensity 2
- Patients who have failed oral triptans or other oral acute treatments 2
Dosing and Administration
- Standard dose is 6 mg subcutaneously at migraine onset 1, 5
- A second dose may be given if headache recurs, but there is no evidence that a second dose helps if the first dose was inadequate 1, 4
- Maximum of two doses in 24 hours 1
Alternative Subcutaneous Options: CGRP Monoclonal Antibodies
While primarily used for prevention rather than acute treatment, three CGRP monoclonal antibodies are administered subcutaneously:
- Erenumab (70 mg or 140 mg monthly) 6
- Fremanezumab (225 mg monthly or 675 mg quarterly) 7
- Galcanezumab (mentioned in guidelines) 2
These are NOT acute treatments - they are preventive medications that reduce migraine frequency over months of use. 2, 8
Critical Contraindications for Subcutaneous Sumatriptan
- Ischemic heart disease or previous myocardial infarction 1, 5
- Prinzmetal (variant) angina 5
- Uncontrolled hypertension 1, 5
- Other significant cardiovascular disease 1
- Concurrent use with ergotamine derivatives or other vasoconstrictive substances 5
- Should not be given during migraine aura 5
Common Adverse Events
- Injection site reactions occur in 10-40% of patients 9, 4
- Chest symptoms occur in 3-5% but myocardial ischemia is rare 5
- Most adverse events are transient, mild, and of short duration 3, 9
- Adverse event rates are higher with subcutaneous administration compared to oral routes, but this is offset by superior efficacy 3, 4
Important Clinical Pearls
- Subcutaneous sumatriptan provides relief within 15 minutes for cluster headache (75% of patients), making it also the treatment of choice for acute cluster attacks 5
- Headache recurrence occurs in 21-57% of responders, usually within 24 hours, but most respond to a second dose 9, 4
- The 8 mg dose offers no clinically meaningful advantage over 6 mg 4
- Limit use to no more than twice weekly to prevent medication-overuse headache 2