Sumatriptan Dosing and Administration for Acute Migraine
For moderate to severe migraine attacks, start with oral sumatriptan 50-100 mg at headache onset when pain is still mild, with the option to repeat once after 2 hours if needed, not exceeding 200 mg in 24 hours. 1
Route Selection Based on Attack Severity
Oral sumatriptan is the appropriate first choice for most patients with moderate to severe migraine who can tolerate oral medication 2, 3:
- 50 mg or 100 mg doses provide superior efficacy compared to 25 mg, with number needed to treat (NNT) of 3.4 for headache relief at 2 hours 4
- The 100 mg dose achieves pain-free response in approximately 28% of patients versus 11% with placebo (NNT 6.1) 4
- Take early in the attack when headache is still mild for optimal effectiveness 2, 3
Subcutaneous sumatriptan 6 mg should be reserved for specific situations 2, 3:
- Patients who rapidly reach peak headache intensity 2
- When oral route is not feasible due to vomiting 2
- When all oral triptans have failed 2
- Provides the highest efficacy: 59% achieve complete pain-free response by 2 hours (NNT 2.3), with relief beginning within 10-15 minutes 4, 5
Intranasal sumatriptan 5-20 mg is indicated when significant nausea or vomiting is present 3
Dosing Algorithm
Initial dose selection 1:
- Start with 50 mg or 100 mg oral (25 mg only if hepatic impairment or concern for tolerability)
- The 100 mg dose may not provide greater effect than 50 mg, but both are superior to 25 mg 1
Repeat dosing 1:
- If headache persists or returns after 2 hours, may repeat the same dose
- Minimum 2-hour interval between doses required
- Maximum 200 mg total in 24 hours 1
For relapse prevention, combine with fast-acting NSAIDs (naproxen sodium, ibuprofen lysine, or diclofenac potassium) to address the 40% of patients who experience symptom recurrence within 48 hours 2
Critical Frequency Limitation
Restrict sumatriptan use to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 2, 3. If acute treatment is needed more frequently, transition to preventive therapy 3.
Contraindications and Safety
Absolute contraindications 6, 7:
- Ischemic heart disease or previous myocardial infarction
- Prinzmetal (variant) angina
- Uncontrolled hypertension
- Basilar or hemiplegic migraine 8
Do not administer during the aura phase - wait until headache begins 2, 6
Hepatic impairment: Maximum single dose 50 mg 1
Common Pitfalls to Avoid
- Taking too late in the attack: Sumatriptan is most effective when taken early while pain is still mild 2, 3
- Inadequate trial before switching: If one triptan fails, try others before escalating to third-line agents, as failure of one does not predict failure of others 2
- Allowing increased frequency: Do not permit patients to increase usage frequency in response to treatment failure; instead optimize acute strategy and initiate preventive therapy 3
- Chest symptoms: Occur in 3-5% of patients but rarely indicate myocardial ischemia; however, evaluate cardiovascular risk factors before prescribing 6, 7
Adverse Events
Oral sumatriptan adverse events include nausea, vomiting, malaise, fatigue, and dizziness, with number needed to harm of 7.1 for the 100 mg dose 4, 7. Subcutaneous administration has higher adverse event rates (injection site reactions in 30-40% of patients) but most are transient and mild to moderate in severity 7, 5.