What are the guidelines for managing a patient's sumatriptan refill for migraines?

Sumatriptan Refill for Migraine Management

Subjective

Key History Points to Document:

• Frequency of migraine attacks per month – if ≥2 attacks/month with ≥3 days disability, preventive therapy should be considered 1
• Current sumatriptan dose, route, and frequency of use – limit acute treatment to no more than twice weekly to prevent medication overuse headache 1, 2
• Number of doses used per month – if rescue medication used >2 times/week, this indicates need for preventive therapy 1
• Effectiveness of current regimen – patients should trial sumatriptan for 2-3 headache episodes before determining efficacy 1, 2
• Timing of medication administration – early administration when pain is mild improves efficacy 1, 2, 3
• Headache recurrence patterns – approximately 40% experience recurrence within 8-12 hours, which can be treated with second dose 2, 4
• Associated symptoms – presence of nausea/vomiting may warrant non-oral route 1, 3
• Triggers and headache diary review – alcohol, caffeine, tyramine-containing foods, stress, fatigue 1

Objective

Cardiovascular Assessment (Critical for Triptan Safety):

• Blood pressure measurement – uncontrolled hypertension is an absolute contraindication 1, 2, 3
• Cardiac history review – coronary artery disease, previous MI, Prinzmetal angina, or vasospastic disease are contraindications 2, 3
• Neurological examination – rule out hemiplegic or basilar migraine (contraindications to triptans) 1, 2, 3

Medication Review:

• Concurrent medications – MAOIs (contraindicated), ergotamine derivatives (24-hour washout required), other triptans (24-hour separation required) 2, 3
• Hepatic function if applicable – mild-moderate hepatic impairment requires maximum 50 mg single dose 5

Assessment

Appropriate Sumatriptan Use: Sumatriptan is indicated as second-line therapy for moderate-to-severe migraines or mild-to-moderate migraines unresponsive to NSAIDs 1, 3. The patient should have tried first-line NSAIDs (aspirin, ibuprofen, naproxen sodium) before escalating to triptans 1, 3.

Medication Overuse Risk:

• If using sumatriptan >2 days/week, medication overuse headache is a significant risk 1, 2
• Frequent triptan use can lead to rebound headaches and requires preventive therapy consideration 1

Contraindication Check:

• Confirm absence of: uncontrolled hypertension, coronary artery disease, hemiplegic/basilar migraine, concurrent MAOI use, pregnancy, use of ergotamines or other triptans within 24 hours 2, 3

Plan

Dosing and Administration

Route Selection Based on Clinical Scenario:

For standard migraine without severe nausea:

• Start with oral sumatriptan 50 mg at onset of headache when pain is still mild 2, 3, 5
• The 50 mg dose provides optimal balance of efficacy and tolerability compared to 25 mg (less effective) or 100 mg (more adverse effects without significantly greater efficacy) 5, 6
• May repeat once after 2 hours if needed, maximum 200 mg per 24 hours 5

For rapid relief needed or severe attacks:

• Subcutaneous 6 mg provides fastest relief (within 15 minutes) with highest efficacy (70-82% response rate) 1, 2, 3
• May repeat once after 1 hour, maximum 12 mg per 24 hours 2

For migraine with significant nausea/vomiting:

• Intranasal 20 mg or subcutaneous route preferred when oral absorption unreliable 1, 3
• Intranasal may be repeated after 2 hours, maximum 40 mg per 24 hours 2

Critical Prescribing Instructions

Timing Strategy:

• Instruct patient to take sumatriptan early when headache is mild, NOT during aura phase 2, 3
• Early administration significantly improves efficacy 1, 2

Medication Overuse Prevention:

• Limit sumatriptan use to maximum 2 days per week 1
• If treating >4 headaches per 30-day period, safety not established 5
• If patient requires more frequent dosing, initiate preventive therapy 1

Headache Recurrence Management:

• Second dose may be taken at least 2 hours after first dose (oral) or 1 hour (subcutaneous) if headache returns 2, 5
• Recurrence occurs in ~40% of patients within 8-12 hours and responds to repeat dosing 2, 4

Drug Interaction Warnings

Mandatory 24-hour washout periods:

• No ergotamine derivatives or DHE within 24 hours before or after sumatriptan 2, 3
• No other triptans within 24 hours 2, 3
• Contraindicated with current MAOI use or within 2 weeks of discontinuation 2, 3

When to Consider Alternative Therapy

If sumatriptan ineffective after 2-3 trials:

• Try a different triptan (rizatriptan 10 mg, eletriptan 40 mg, or zolmitriptan) – different triptans work for different patients even when one fails 1, 2, 3

If NSAIDs + triptan monotherapy insufficient:

• Combine triptan with fast-acting NSAID (naproxen sodium, ibuprofen, or diclofenac potassium) 3

Preventive Therapy Indications

Initiate preventive medication if:

• ≥2 migraine attacks per month with ≥3 days disability 1
• Rescue medication use >2 times per week 1
• Failure of or contraindications to acute treatments 1

Patient Education

Adverse effects to expect:

• Cardiovascular sensations (chest pressure, heaviness, warmth) occur in 3-5% of patients and are generally benign 2
• Most adverse events are mild-moderate, short duration, and more common with subcutaneous route 7

Red flags requiring immediate evaluation:

• Chest pain suggestive of cardiac ischemia
• Neurological symptoms beyond typical migraine aura
• Severe hypertension

Follow-up

• Reassess in 4-6 weeks or sooner if medication overuse suspected
• Review headache diary to track frequency, severity, disability, and treatment response 1
• Evaluate need for preventive therapy if acute medication use exceeds recommended limits 1