What is the recommended dose of Sumatriptan for an adult patient between 18 and 65 years old with no history of cardiovascular disease (CVD) or other contraindications, experiencing migraine headaches?

Sumatriptan 100mg Dosing for Acute Migraine

For adults aged 18-65 with no cardiovascular contraindications experiencing moderate to severe migraine, oral sumatriptan 100mg is an appropriate and effective dose, though 50mg may provide similar efficacy with better tolerability. 1

Recommended Dosing Strategy

The FDA-approved dosing for oral sumatriptan is 25mg, 50mg, or 100mg, with the 50mg and 100mg doses providing greater effect than 25mg, though 100mg may not provide substantially greater benefit than 50mg while carrying higher risk of adverse effects. 1

Initial Dose Selection

• Start with 50mg or 100mg oral sumatriptan at migraine onset when pain is still mild for optimal effectiveness. 2, 3
• The 100mg dose achieves headache relief in 50-67% of patients at 2 hours compared to 10-31% with placebo. 4
• Patient preference studies show 35% prefer 100mg, 31% prefer 50mg, and 25% prefer 25mg, with efficacy and speed of action being the main reasons for preferring higher doses. 5
• The 50mg dose likely has the best effectiveness-to-tolerability ratio, though some patients clearly benefit from the higher 100mg dose. 5

Repeat Dosing Parameters

• If migraine has not resolved by 2 hours or returns after transient improvement, administer a second dose at least 2 hours after the first dose. 1
• The maximum daily dose is 200mg in a 24-hour period. 1
• Approximately 40% of patients experience headache recurrence within 8-12 hours after initial response, which can be effectively treated with a second dose. 2, 4

Critical Timing Considerations

• Administer sumatriptan early in the headache phase when pain is still mild—do NOT take during the aura phase as there is no evidence of benefit. 3
• Patients must trial sumatriptan for 2-3 headache episodes before determining if it is effective, as different triptans work for different patients even when one fails. 2, 6, 3

Medication Overuse Prevention

Limit sumatriptan use to no more than twice per week (approximately 8-9 treatment days per month) to prevent medication-overuse headache. 6

• Frequent, repeated use risks development of medication-overuse headache and can transform episodic migraine into chronic daily headache. 2, 6
• The safety of treating more than 4 headaches in a 30-day period has not been established. 1
• This translates to a maximum monthly prescription of approximately 18 tablets (9 treatment days × 2 tablets per attack), though a more conservative approach of 8-16 tablets per month is prudent. 6

Combination Therapy Approach

If 100mg sumatriptan provides insufficient relief, add an NSAID (naproxen, ibuprofen, or diclofenac) or acetaminophen rather than increasing triptan frequency. 7, 6, 3

• The American College of Physicians recommends adding a triptan to an NSAID or acetaminophen when adequate doses of NSAID/acetaminophen alone provide insufficient pain relief. 7
• Combination therapy of triptan plus NSAID is more effective than increasing triptan dose or frequency. 3

Absolute Contraindications

Do not administer sumatriptan to patients with: 2, 3

• Coronary artery disease, previous myocardial infarction, or Prinzmetal angina
• Hemiplegic or basilar migraine
• Uncontrolled hypertension
• Within 24 hours of ergotamine, dihydroergotamine (DHE), or another triptan
• Current MAOI use or within 2 weeks of discontinuation

Hepatic Impairment Adjustment

• In patients with mild to moderate hepatic impairment, the maximum single dose should not exceed 50mg. 1

Common Adverse Effects

• Chest symptoms (pressure, heaviness, or warmth) occur in 3-5% of patients but have rarely been associated with myocardial ischemia. 2, 4
• Other common adverse events include nausea, vomiting, malaise, fatigue, and dizziness, with overall adverse event incidence of 30% for the 100mg dose versus 21% for 50mg and 19% for 25mg. 4, 5
• The number-needed-to-harm for adverse events with 100mg versus placebo is 7.1. 8

Alternative Triptan Consideration

If inadequate response occurs after appropriate dosing of sumatriptan for 2-3 attacks, switch to another triptan (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, or zolmitriptan) as different triptans work for different patients. 7, 2, 3