Sumatriptan Dosing for Migraine
For oral sumatriptan, start with 50 mg or 100 mg at migraine onset, as these doses provide superior efficacy compared to 25 mg, with the 50 mg dose offering the best effectiveness-to-tolerability ratio. 1
Oral Dosing Recommendations
The FDA-approved oral doses are 25 mg, 50 mg, or 100 mg, with 50 mg and 100 mg providing greater effect than 25 mg, though 100 mg may not provide greater effect than 50 mg but carries higher risk of adverse reactions. 1
The maximum single oral dose is 100 mg, and if the migraine has not resolved by 2 hours or returns after transient improvement, a second dose may be administered at least 2 hours after the first dose. 1
The maximum daily dose is 200 mg in a 24-hour period. 1
Patient preference studies show 35% prefer 100 mg, 31% prefer 50 mg, and 25% prefer 25 mg, with efficacy and speed of action being the main reasons for preferring higher doses. 2
The 50 mg and 100 mg doses achieve headache relief in 50-56% of patients by 2 hours and 68-71% by 4 hours, compared to only 26% and 38% with placebo, respectively. 3
Route-Specific Dosing
Subcutaneous sumatriptan 6 mg provides the highest efficacy with 70-82% of patients achieving relief within 15 minutes and 59% achieving complete pain relief by 2 hours, making it the most effective route for severe attacks or when rapid onset is needed. 4, 5
Intranasal sumatriptan 5-20 mg is recommended for moderate to severe attacks when significant nausea or vomiting is present, with 70-80% of patients achieving relief within 1 hour. 4, 5
After initial treatment with subcutaneous sumatriptan injection, additional oral sumatriptan tablets (up to 100 mg/day) may be given with an interval of at least 2 hours between doses. 1
Special Populations
- In patients with mild to moderate hepatic impairment, the maximum single oral dose should not exceed 50 mg. 1
Critical Frequency Limitation
Limit sumatriptan use to no more than 2 days per week (or treating an average of 4 headaches per 30-day period) to prevent medication-overuse headache, which can paradoxically increase headache frequency and lead to daily headaches. 4, 1
If patients require acute treatment more than twice weekly, initiate preventive therapy immediately rather than increasing frequency of sumatriptan use. 4
Cardiovascular Risk Assessment
Sumatriptan is absolutely contraindicated in patients with ischemic heart disease, previous myocardial infarction, Prinzmetal angina, uncontrolled hypertension, or other significant cardiovascular disease due to its vasoconstrictive properties. 4, 6
Do not administer sumatriptan together with ergotamine-containing medications or within 24 hours of each other. 6
Avoid giving sumatriptan during the migraine aura phase. 6
Headache Recurrence Management
Approximately 40% of patients experience migraine recurrence within 24-48 hours after initial symptom resolution, regardless of route of administration, likely related to sumatriptan's short 2-hour half-life. 5, 7
Most patients who experience recurrence respond effectively to a second dose of sumatriptan, administered at least 2 hours after the first dose. 1, 7
The median time to recurrence increases with dose, from 8.5 hours with 25 mg to 11.8 hours with 100 mg. 2
Combination Therapy for Enhanced Efficacy
For moderate to severe migraine, combining sumatriptan with an NSAID (such as naproxen 500 mg) provides superior efficacy compared to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours. 4
Adding an antiemetic (metoclopramide 10 mg or prochlorperazine 25 mg) 20-30 minutes before sumatriptan can provide synergistic analgesia and improve outcomes. 4