What are the instructions for taking sumatriptan (Imitrex) 25 mg tablets for a patient with migraines, considering potential contraindications such as cardiovascular disease and uncontrolled hypertension?

Sumatriptan 25 mg Tablet Instructions for Migraine

Take sumatriptan 25 mg as a single tablet at the onset of migraine headache, and if needed, a second dose may be taken at least 2 hours after the first dose only if you experienced some response to the initial dose, with a maximum of 200 mg (eight 25 mg tablets) in 24 hours. 1

Dosing Instructions

• Take the tablet whole with water at the first sign of migraine headache pain 1
• The 25 mg dose is the lowest available strength and may be appropriate for initial treatment or for patients who experience side effects with higher doses 2
• Do not take a second dose if the first dose provided no relief whatsoever—contact your healthcare provider instead 1
• If headache returns or you get only partial relief, you may take a second 25 mg tablet at least 2 hours after the first dose 1
• Maximum daily dose: 200 mg total (eight 25 mg tablets) in any 24-hour period 1

Critical Timing Considerations

• Take sumatriptan early in the migraine attack while pain is still mild for maximum effectiveness 3
• Do not take sumatriptan during the aura phase before headache begins 4
• Limit use to no more than 2 days per week to prevent medication-overuse headache, which paradoxically worsens headache frequency 3, 1

Absolute Contraindications—Do Not Take If You Have:

• Uncontrolled hypertension 1
• Any history of heart disease, coronary artery disease, angina, heart attack, or coronary artery vasospasm 1
• History of stroke or transient ischemic attack (TIA) 1
• Peripheral vascular disease (narrowing of blood vessels to legs, arms, stomach, or kidneys) 1
• Hemiplegic or basilar migraine 1
• Severe liver impairment 1
• Taken another triptan or ergotamine-containing medication within the past 24 hours 1
• Taken a monoamine oxidase inhibitor (MAOI) within the past 2 weeks 1

When to Seek Immediate Medical Attention

Stop taking sumatriptan and seek emergency care if you experience:

• Chest pain, tightness, pressure, or heaviness (though usually not cardiac in origin, requires evaluation in high-risk patients) 1
• Sudden severe stomach pain, bloody diarrhea, or abdominal pain after meals (signs of gastrointestinal ischemia) 1
• Cramping, pain, coldness, or color changes in legs or feet (peripheral vascular ischemia) 1
• Signs of stroke: sudden severe headache, weakness, vision changes, slurred speech 1
• Serotonin syndrome symptoms: agitation, hallucinations, fast heartbeat, high fever, muscle rigidity, confusion (especially if taking antidepressants) 1

Common Side Effects (Usually Mild and Transient)

• Tingling or numbness in fingers, toes, or face (paresthesias) 5, 6
• Sensations of warmth, pressure, tightness, or heaviness in chest, neck, throat, or jaw 5, 1
• Dizziness, drowsiness, fatigue, or malaise—do not drive or operate machinery if these occur 1
• Nausea or dry mouth 5

These side effects occur in 3-5% of patients and typically resolve quickly 5

Special Precautions for Cardiovascular Risk Factors

• If you have multiple cardiovascular risk factors (high blood pressure, high cholesterol, diabetes, smoking, obesity, family history of heart disease), your first dose should be taken in a medical setting under supervision 1
• Your healthcare provider should perform cardiac evaluation before prescribing if you have cardiovascular risk factors 1
• Blood pressure should be monitored regularly during treatment, especially in older patients 7

Drug Interactions Requiring Caution

• Do not combine with other triptans, ergotamine medications, or MAO inhibitors 1
• Use with caution if taking antidepressants (SSRIs, SNRIs, tricyclics) due to risk of serotonin syndrome 1
• Inform your healthcare provider of all medications you take before starting sumatriptan 1

When to Consider Alternative Treatment

• If sumatriptan 25 mg fails to provide relief after trying it for 2-3 separate migraine attacks, contact your provider to try a higher dose (50 mg or 100 mg) or switch to a different triptan 3, 6
• The 25 mg dose has lower efficacy than 50 mg or 100 mg doses but also fewer side effects 2
• If you require acute migraine treatment more than 2 days per week, you need preventive therapy rather than increased acute medication use 3

Pregnancy and Breastfeeding

• Sumatriptan may cause fetal harm based on animal data 1
• Sumatriptan passes into breast milk—discuss feeding options with your provider if breastfeeding 1