What is the next step for an adult patient with a history of migraines who did not respond to sumatriptan (Imigran) for an acute migraine?

Next Step for Acute Migraine After Sumatriptan Failure

Try a different triptan immediately—failure of one triptan does not predict failure of others, with 25-81% of sumatriptan non-responders achieving pain relief with an alternative triptan. 1, 2

Immediate Alternative Triptan Options

Switch to one of these alternative triptans for the current or next migraine attack:

• Rizatriptan 10 mg - reaches peak concentration fastest among oral triptans (60-90 minutes) and may work when sumatriptan fails 1, 3
• Eletriptan 40 mg - demonstrated efficacy in sumatriptan non-responders 2
• Zolmitriptan 2.5-5 mg - effective alternative with different pharmacokinetic profile 1, 2
• Naratriptan 2.5 mg - slower onset but lower recurrence rate, useful for longer-lasting attacks 2, 4

The evidence is clear: clinical trials consistently show that 25-81% of patients who respond poorly to sumatriptan will respond to a different triptan, making this the most logical first step. 2

Consider Route Change if Oral Sumatriptan Failed

If the patient used oral sumatriptan, consider:

• Subcutaneous sumatriptan 6 mg - provides highest efficacy (59% complete pain relief at 2 hours) with onset within 15 minutes, particularly effective for rapid progression to peak intensity or significant nausea/vomiting 1, 3
• Intranasal sumatriptan 5-20 mg - bypasses gastric absorption issues 1

Combination Therapy Strategy

Combine the alternative triptan with a fast-acting NSAID to prevent relapse and enhance efficacy:

• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg provides superior efficacy compared to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1
• This combination addresses the 40% of patients who experience symptom recurrence within 48 hours 1
• Take both medications together early in the attack while pain is still mild 1, 3

Add Antiemetic for Synergistic Analgesia

Don't restrict antiemetics only to patients with vomiting—they provide direct analgesic benefit:

• Metoclopramide 10 mg (oral or IV) given 20-30 minutes before or with the triptan provides synergistic analgesia through central dopamine receptor antagonism 1, 3
• Prochlorperazine 10 mg IV or 25 mg oral/suppository provides comparable efficacy to metoclopramide 1, 3

Third-Line Options if All Triptans Fail

If the patient has tried multiple triptans without adequate response:

• Gepants (CGRP antagonists): Ubrogepant 50-100 mg or rimegepant—no vasoconstriction, safe for cardiovascular disease 1
• Lasmiditan 50-200 mg: 5-HT1F agonist without vasoconstrictor activity, but patients cannot drive for 8 hours after use 5, 1
• Dihydroergotamine (DHE): Intranasal or IV formulation for severe attacks 1, 3

Critical Frequency Limitation

Limit all acute migraine medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache. 1, 3 If the patient requires acute treatment more frequently, initiate preventive therapy immediately rather than increasing acute medication frequency. 1

When to Initiate Preventive Therapy

Start preventive therapy now if the patient:

• Uses acute medications more than twice weekly 5, 1
• Has two or more attacks per month producing disability lasting 3+ days 1, 3
• Continues to have impaired quality of life despite optimized acute therapy 5

First-line preventive options include propranolol 80-240 mg/day, timolol 20-30 mg/day, amitriptyline 30-150 mg/day, or topiramate. 5, 3 Preventive therapy reduces attack frequency and can restore responsiveness to acute treatments. 1

Medications to Absolutely Avoid

• Opioids and butalbital compounds: Questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time 5, 1
• Oral ergot alkaloids: Poorly effective and potentially toxic 5

Common Pitfall to Avoid

Do not allow the patient to simply increase the frequency of sumatriptan use or switch to opioids—this creates a vicious cycle of medication-overuse headache leading to daily headaches. 1, 3 The correct approach is to optimize the acute treatment strategy (different triptan + NSAID + antiemetic) while simultaneously addressing frequency with preventive therapy if needed. 1