Injectable Medications for Migraine Treatment
Subcutaneous sumatriptan 6 mg is the most effective and rapidly acting injectable medication for acute migraine, providing complete pain relief in approximately 59% of patients within 2 hours, with onset of action within 15 minutes. 1, 2, 3
Primary Injectable Option: Subcutaneous Sumatriptan
Subcutaneous sumatriptan 6 mg represents the gold standard for injectable migraine treatment, achieving the highest efficacy rates among all triptan formulations and routes of administration. 1, 2
Dosing and Administration
- Standard dose: 6 mg subcutaneously at migraine onset 1, 2, 4
- Maximum: Two 6 mg doses in 24 hours, separated by at least 1 hour 4
- Onset of action: 15 minutes, with 70-82% of patients experiencing relief within 1-2 hours 2, 5, 3
- Available as needle-free injection system (Sumavel DosePro) for patients with needle phobia 6, 7
When to Use Subcutaneous Sumatriptan
- Patients who rapidly reach peak headache intensity 1
- Presence of significant nausea or vomiting preventing oral medication use 1, 2
- Failure of oral triptans in previous attacks 1, 7
- Need for most rapid and reliable pain relief 2, 3
Critical Contraindications
Do not administer subcutaneous sumatriptan if the patient has: 4, 5
- Ischemic heart disease, previous myocardial infarction, or coronary artery disease
- Uncontrolled hypertension
- Hemiplegic or basilar migraine
- Recent use (within 24 hours) of ergotamine-containing medications or another triptan
- Prinzmetal (variant) angina
Common Side Effects
- Injection site reactions occur in 10-40% of patients but typically last less than 1 hour 4, 5, 8
- Chest pressure, tightness, or heaviness in 3-5% of patients 9, 5
- Tingling, warmth, flushing, or heaviness sensations 9, 4
- Nausea, dizziness, drowsiness, or fatigue 4, 5
Alternative Injectable Option: Intravenous Dihydroergotamine (DHE)
For patients with contraindications to triptans or when triptans have failed, IV dihydroergotamine provides good efficacy as monotherapy. 1, 2
Key Advantages of DHE
- Lower headache recurrence rate compared to sumatriptan 8
- Effective alternative when cardiovascular contraindications preclude triptan use 2
Important Contraindication
DHE cannot be used within 24 hours of triptan administration or in patients taking ergotamine-containing medications. 1, 4
Intravenous Migraine Cocktail (Non-Triptan Injectable Option)
For patients requiring IV treatment in urgent care or emergency settings, the combination of metoclopramide 10 mg IV plus ketorolac 30 mg IV provides first-line therapy. 2
Components and Rationale
- Metoclopramide 10 mg IV: Provides direct analgesic effects through central dopamine receptor antagonism, not just antiemetic action 2
- Ketorolac 30 mg IV: Rapid onset with approximately 6 hours duration and minimal rebound headache risk 2
- Prochlorperazine 10 mg IV: Alternative to metoclopramide with comparable efficacy 2
Critical Frequency Limitation to Prevent Medication-Overuse Headache
Limit all injectable acute migraine medications to no more than 2 days per week. 1, 2 Using injectable medications more frequently can paradoxically increase headache frequency and lead to daily headaches through medication-overuse headache. 1, 2
If a patient requires injectable treatment more than twice weekly, immediately initiate preventive therapy rather than increasing acute medication frequency. 2
Clinical Algorithm for Injectable Selection
First-line: Subcutaneous sumatriptan 6 mg for most patients requiring injectable therapy 1, 2, 3
Screen for cardiovascular contraindications before administering any triptan 1, 4
If triptans contraindicated or failed: Use IV metoclopramide 10 mg + ketorolac 30 mg 2
If both triptans and NSAIDs contraindicated: Consider IV dihydroergotamine 2
For cluster headache specifically: Subcutaneous sumatriptan 6 mg provides relief in 75% of patients within 15 minutes 1, 5