Yes, Imitrex (sumatriptan) is an appropriate next step for this patient with migraine unresponsive to Excedrin.
When NSAIDs or combination analgesics like Excedrin fail to control a migraine attack, triptans such as sumatriptan are the recommended second-line therapy for moderate to severe migraine. 1, 2
Treatment Algorithm for Failed NSAID/Combination Therapy
Immediate Management
- Administer sumatriptan 50-100 mg orally as soon as possible while the headache is still at moderate intensity, as early administration improves efficacy 2, 3
- The 50 mg and 100 mg doses show equivalent efficacy (61-62% headache response at 2 hours vs 27% with placebo), with no significant difference between these doses 3, 4
- Start with 50 mg as the initial dose, since there is no evidence that 100 mg provides greater effect than 50 mg 3
Expected Outcomes
- 50-56% of patients achieve headache relief (reduction from moderate/severe to mild/no pain) by 2 hours post-dose 3, 4
- 68-71% achieve relief by 4 hours 3, 4
- Sumatriptan also reduces associated symptoms including nausea, photophobia, and phonophobia 3
Critical Frequency Limitation
- Limit sumatriptan use to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 2
- If the patient requires acute treatment more than twice weekly, initiate preventive therapy immediately with propranolol 80-240 mg/day, amitriptyline 30-150 mg/day, or divalproex sodium 500-1500 mg/day 1, 2
Enhanced Strategy: Combination Therapy
For optimal efficacy, consider prescribing sumatriptan 50-100 mg PLUS naproxen sodium 500 mg to be taken together at migraine onset. 2 This combination is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to monotherapy 2
Contraindications to Screen For
Before prescribing sumatriptan, ensure the patient does not have: 3, 5
- Ischemic heart disease or previous myocardial infarction
- Uncontrolled hypertension
- Vasospastic coronary disease (Prinzmetal's angina)
- Peripheral vascular disease
- Cerebrovascular disease (stroke or TIA)
Alternative Routes if Oral Fails
If oral sumatriptan proves ineffective after 2-3 migraine episodes, consider: 2, 6
- Subcutaneous sumatriptan 6 mg, which achieves 59% complete pain relief by 2 hours with onset within 15 minutes—significantly superior to oral formulations 2, 6
- This route is particularly useful for patients with rapid progression to peak intensity or significant nausea/vomiting 2
When to Escalate Further
If sumatriptan fails after adequate trials (treating 2-3 attacks early while pain is mild): 2, 7
- Try a different triptan, as failure of one does not predict failure of others (consider rizatriptan, zolmitriptan, or naratriptan) 2
- Consider CGRP antagonists (rimegepant, ubrogepant, zavegepant) as alternatives 2, 7
- Evaluate for preventive therapy if not already initiated 1, 2
Common Pitfall to Avoid
Do not allow the patient to increase frequency of Excedrin use while waiting for sumatriptan to work. Frequent use of combination analgesics (more than 2 days per week) creates medication-overuse headache, worsening the migraine pattern 1, 2. Transition to preventive therapy rather than escalating acute medication frequency 2, 6