Sumatriptan Dosing for Acute 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 a maximum daily dose of 200 mg in 24 hours. 1
Route-Specific Dosing Recommendations
Oral Administration
- Initial dose: 25 mg, 50 mg, or 100 mg 1
- The 50 mg and 100 mg doses provide greater effect than 25 mg, though 100 mg may not provide substantially greater benefit than 50 mg 1
- If headache persists or returns after 2 hours, a second dose may be given with at least 2 hours between doses 1
- Maximum daily dose: 200 mg in 24 hours 2, 1
- Oral sumatriptan achieves headache relief in 50-73% of patients within 2 hours 3
Subcutaneous Administration
- Dose: 6 mg at migraine onset 2
- May repeat once after 1 hour if needed 2
- Maximum: 12 mg per 24 hours 2
- This route provides the fastest relief (within 15 minutes) and highest efficacy (70-82% response rate) 2, 4
- Pain reduced to none in almost 6 in 10 patients (59%) within 2 hours, compared to 15% with placebo 4
Intranasal Administration
- Dose: 5-20 mg 2
- May repeat after 2 hours 2
- Maximum: 40 mg per 24 hours 2
- The 20 mg dose is most effective for headache relief at 2 hours 4
Critical Timing and Trial Considerations
Administer sumatriptan early in the headache phase for optimal effectiveness 5. Taking medication when pain is still mild is more effective than waiting until pain becomes moderate or severe 4.
Patients must trial sumatriptan for 2-3 migraine episodes before determining effectiveness 2. If one triptan fails, trying a different triptan is reasonable as different triptans work for different patients 2.
Managing Headache Recurrence
Approximately 40% of patients experience headache recurrence within 8-12 hours after initial response 2, 3. A second dose following minimum interval requirements effectively treats recurrence 2.
Hepatic Impairment Dosing
In mild to moderate hepatic impairment, maximum single dose should not exceed 50 mg 1.
Absolute Contraindications
- Coronary artery disease, previous myocardial infarction, or Prinzmetal angina 2, 6
- Hemiplegic or basilar migraine 2, 6
- Uncontrolled hypertension 2, 6
- Within 24 hours of another triptan or ergotamine derivatives 2
- Current MAOI use 2
Common Adverse Effects
Cardiovascular sensations (chest pressure, heaviness, or warmth) occur in 3-5% of patients 2. Adverse events are generally mild, transient, and more common with subcutaneous administration and higher oral doses 4. The subcutaneous route shows highest adverse event rates (approximately 30% injection site reactions) 6.
Medication Overuse Warning
Frequent, repeated use of sumatriptan risks development of medication overuse headache 5. The safety of treating more than 4 headaches in a 30-day period has not been established 1.