What is the interaction between Topiramate and Sumatriptan (Imitrex)?

From the Guidelines

Topiramate and sumatriptan should not be used on the day of surgical procedures due to potential drug-drug interactions and the risk of serotonin syndrome. When considering the use of topiramate and sumatriptan together, it's essential to weigh the benefits against the potential risks, particularly in the context of surgical procedures. Topiramate is an anticonvulsant often prescribed as a preventive medication for migraines, typically starting at 25mg daily and gradually increasing to 50-200mg daily in divided doses. Sumatriptan, a triptan medication, is used for acute migraine treatment, available in various forms including oral tablets (25-100mg per dose), nasal sprays, and injections. According to the Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement 1, there are theoretical concerns regarding drug-drug interactions with triptans, such as sumatriptan, and some commonly used perioperative medications.

• The risk of serotonin syndrome with combining triptans and SSRIs or SNRIs is low, but it's still a concern.
• Some triptans, including sumatriptan, have routes of metabolism that include monoamine oxidase A, CYP3A4, CYP2D6, and CYP1A2, which may interact with other medications.
• The consensus is to avoid these medications on the day of surgical procedures and use an alternative treatment for acute headache, if needed, as stated in the SPAQI consensus statement 1. In clinical practice, the combination of topiramate and sumatriptan requires careful management and monitoring by a healthcare provider to ensure effectiveness and minimize adverse effects, especially since both medications can affect the central nervous system. However, in the context of surgical procedures, the potential risks associated with sumatriptan outweigh its benefits, and alternative treatments should be considered.

From the FDA Drug Label

Sumatriptan: Multiple dosing of topiramate (100 mg every 12 hrs) in 24 healthy volunteers (14 M, 10 F) did not affect the pharmacokinetics of single dose sumatriptan either orally (100 mg) or subcutaneously (6 mg). The use of topiramate and sumatriptan together does not appear to have a significant interaction, as topiramate does not affect the pharmacokinetics of sumatriptan 2.

• Key points:
  • No significant effect on sumatriptan pharmacokinetics
  • Topiramate and sumatriptan can be used together without dose adjustment
  • Patients should still be monitored for clinical response and any potential side effects 2

From the Research

Topiramate and Sumatriptan

• There is no direct evidence comparing the use of topiramate and sumatriptan together in the provided studies.
• However, the studies provide information on the individual use of sumatriptan and topiramate in the treatment of migraine:
  • Sumatriptan is a triptan used for the acute treatment of migraine attacks, and its effectiveness has been demonstrated in several studies 3, 4, 5, 6.
  • Topiramate is used for migraine prevention, and its efficacy has been established in randomized controlled trials 7.
• The combination of sumatriptan and naproxen has been shown to be effective in the acute treatment of migraine, with a faster onset of action and better efficacy than monotherapy with either sumatriptan or naproxen 3, 6.
• Topiramate has been found to reduce migraine frequency, improve quality of life, and reduce disability in patients with episodic and chronic migraine 7.
• The use of sumatriptan in patients with psychiatric comorbidities, such as major depressive disorder and obsessive-compulsive disorder, should be done with caution due to the potential interaction with serotonin 4.