What is the recommended dose of sumatriptan (Imitrex) for migraine headaches?

Sumatriptan Dosing for Migraine Headaches

For acute migraine treatment, start with oral sumatriptan 50-100 mg at headache onset, with 50 mg offering the optimal balance of efficacy and tolerability for most patients. 1, 2

Route-Specific Dosing Options

The choice of administration route depends on severity of symptoms and speed of relief needed:

Oral Administration (First-Line for Most Patients)

• Start with 50 mg or 100 mg at migraine onset 1, 2
• The 50 mg dose provides the best efficacy-to-tolerability ratio, though some patients require 100 mg 1
• If headache persists or returns after 2 hours, a second dose may be taken with at least 2 hours between doses 2
• Maximum daily dose: 200 mg per 24 hours 1, 2
• The 25 mg dose is less effective and generally not recommended as initial therapy 2

Subcutaneous Administration (Fastest Relief)

• 6 mg subcutaneously provides the most rapid relief (within 15 minutes) with highest efficacy (70-82% response rate) 1
• May repeat once after 1 hour if needed 1, 3
• Maximum daily dose: 12 mg per 24 hours 1, 3
• Injection site reactions occur in approximately 30% of patients 3

Intranasal Administration

• 5-20 mg (typically 5-10 mg in one nostril) 1, 3
• May repeat after 2 hours if needed 1, 3
• Maximum daily dose: 40 mg per 24 hours 1, 3

Critical Timing Considerations

• Administer early in the headache phase when pain is still mild for optimal effectiveness 1
• Do not use during migraine aura 4
• Patients must try sumatriptan for 2-3 headache episodes before determining efficacy 1, 3

Managing Inadequate Response

If 50-100 mg oral sumatriptan provides insufficient relief:

• Add an NSAID or acetaminophen rather than increasing triptan frequency 3, 5
• Consider switching to subcutaneous route for faster, more complete relief 1
• If response remains inadequate after proper dosing trials, switch to a different triptan (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, or zolmitriptan) 3
• Consider adding an antiemetic for patients with severe nausea or vomiting 3

Headache Recurrence Management

• Approximately 40% of patients experience headache recurrence within 8-12 hours 1, 6
• This can be effectively treated with a second dose following minimum interval requirements (2 hours for oral, 1 hour for subcutaneous) 1, 2

Absolute Contraindications

Do not prescribe sumatriptan in patients with: 1, 3

• Coronary artery disease, previous myocardial infarction, or Prinzmetal angina
• Hemiplegic or basilar migraine
• Uncontrolled hypertension
• Current MAOI use or within 14 days of discontinuation

Critical Drug Interactions

• 24-hour washout period required between sumatriptan and any other triptan 1, 5
• 24-hour washout period required between sumatriptan and ergotamine or dihydroergotamine (DHE) in either direction 1, 3
• Contraindicated with concurrent MAOI use 1, 3

Medication Overuse Headache Prevention

This is the most common prescribing pitfall:

• Limit use to no more than twice per week (8-9 treatment days per month maximum) 5
• Using triptans more frequently can transform episodic migraine into chronic daily headache 5
• The FDA notes that safety of treating more than 4 headaches in a 30-day period has not been established 2
• Patients must understand this risk explicitly when receiving their prescription 5

Special Population: Hepatic Impairment

• In mild to moderate hepatic impairment, maximum single dose should not exceed 50 mg 2

Common Adverse Effects

• Chest pressure, heaviness, or warmth occurs in 3-5% of patients (rarely associated with actual myocardial ischemia) 1, 3
• Nausea, warmth, vomiting, vertigo, malaise, and headache may occur 3
• Most adverse events are transient and dose-related 1