What is the dose and duration of sumatriptan (Imitrex) for a patient with migraines?

Sumatriptan Dosing for Acute Migraine

For oral sumatriptan, start with 50-100 mg at the onset of migraine symptoms (when pain is still mild), which can be repeated once after 2 hours if needed, with a maximum of 200 mg per 24 hours. 1, 2

Initial Dose Selection

• The oral 50 mg dose offers the optimal balance of efficacy and tolerability for most patients, though the 100 mg dose provides greater efficacy and is well-tolerated by many 1, 2
• The 25 mg dose is less effective and should be reserved for patients with hepatic impairment (maximum 50 mg single dose in this population) 2
• Take the medication early when headache pain is still mild—this is crucial for maximum effectiveness, as waiting until pain becomes moderate or severe significantly reduces treatment success 3
• Do not take sumatriptan during the aura phase, as there is no evidence of benefit when taken before headache onset 3

Alternative Routes for Faster Relief

If oral administration is inadequate or faster relief is needed:

• Subcutaneous 6 mg provides the fastest relief (within 15 minutes) and highest efficacy (70-82% response rate), can be repeated once after 1 hour, maximum 12 mg per 24 hours 1, 4
• Intranasal 5-20 mg can be repeated after 2 hours, maximum 40 mg per 24 hours 1, 4

Repeat Dosing for Headache Recurrence

• Approximately 40% of patients experience headache recurrence within 8-12 hours after initial response, which can be effectively treated with a second dose 1, 3
• For oral sumatriptan, wait at least 2 hours between doses 2
• For subcutaneous sumatriptan, wait at least 1 hour between doses 1

Duration of Trial Period

• Patients must try sumatriptan for 2-3 separate migraine episodes before determining if it is effective 3, 4
• If inadequate response after proper dose optimization across multiple attacks, switch to a different triptan (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, or zolmitriptan), as different triptans work for different patients 1, 4

Combination Therapy for Insufficient Relief

• If 100 mg sumatriptan provides insufficient relief, add an NSAID (naproxen, ibuprofen, or diclofenac) or acetaminophen rather than increasing triptan frequency 1, 3
• Combination therapy of triptan plus NSAID is more effective than increasing triptan dose or frequency 1

Medication Overuse Warning

• Limit use to no more than 4 headaches per 30-day period to avoid medication overuse headache 3, 2
• The safety of treating more than 4 headaches in a 30-day period has not been established 2

Critical Contraindications

Absolute contraindications include:

• Coronary artery disease, previous myocardial infarction, or Prinzmetal angina 1, 3
• Hemiplegic or basilar migraine 1, 3
• Uncontrolled hypertension 1
• Within 24 hours of ergotamine derivatives or another triptan 1, 3
• Current MAOI use or within 2 weeks of discontinuation 3
• Pregnancy and severe hepatic impairment 3

Common Adverse Effects

• Mild to moderate adverse events occur in 3-5% of patients, including chest pressure/heaviness, warmth sensation, nausea, vomiting, vertigo, and malaise 3, 4
• Subcutaneous administration causes injection site reactions in approximately 30% of patients 4