What alternative medication can be given to an adult patient with a history of migraines who can no longer take Sumatriptan (Imitrex)?

Alternative Medications for Patients Unable to Take Sumatriptan

If a patient can no longer take sumatriptan (Imitrex), the best alternative is to try a different triptan first, such as rizatriptan 10 mg or zolmitriptan 2.5-5 mg, as failure of one triptan does not predict failure of others. 1

First-Line Alternative: Switch to Another Triptan

• Try rizatriptan 10 mg as the preferred alternative triptan, as it reaches peak concentration in 60-90 minutes, making it the fastest oral triptan, and has demonstrated superior efficacy compared to other triptans 1, 2
• Rizatriptan 10 mg provides faster pain relief and a higher percentage of patients with absence of pain at 2 hours compared to naratriptan 2.5 mg or zolmitriptan 2.5 mg 1
• Alternative triptan options include eletriptan 40 mg or zolmitriptan 2.5-5 mg if rizatriptan is not suitable 1
• The American Academy of Family Physicians recommends trying a different triptan if one fails after 2-3 headache episodes, as failure of one does not predict failure of others 1

Second-Line Alternative: CGRP Antagonists (Gepants)

• If all triptans fail or are contraindicated, use gepants (ubrogepant 50-100 mg or rimegepant) as the primary oral alternative for moderate to severe migraine 1
• Gepants have no vasoconstriction, making them safe for patients with cardiovascular disease, uncontrolled hypertension, or cerebrovascular disease—common contraindications for triptans 1
• The American Academy of Neurology recommends gepants as first-line alternatives when triptans are contraindicated due to their strong evidence-based efficacy 1

Third-Line Alternative: Ditans

• Lasmiditan (Reyvow) 50-200 mg is a 5-HT1F receptor agonist without vasoconstrictor activity, recommended by the American Headache Society as a second-line option when gepants are unavailable or ineffective 1
• Critical warning: Patients must not drive or operate machinery for at least 8 hours after taking lasmiditan due to CNS effects including dizziness, vertigo, somnolence, and fatigue 1

Non-Triptan Acute Treatment Options

• For mild to moderate migraine, NSAIDs remain first-line therapy: naproxen sodium 500-825 mg or ibuprofen 400-800 mg at migraine onset 1
• For moderate to severe attacks requiring IV treatment, use metoclopramide 10 mg IV plus ketorolac 30 mg IV as first-line combination therapy 1
• Intranasal dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy for acute migraine attacks 1

Critical Frequency Limitation to Prevent Medication-Overuse Headache

• Limit all acute migraine medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache, which can paradoxically increase headache frequency and lead to daily headaches 1
• If the patient requires acute treatment more than twice weekly, initiate preventive therapy immediately rather than increasing frequency of acute medications 1

Common Pitfalls to Avoid

• Do not assume all triptans will fail if sumatriptan failed—different triptans have different pharmacokinetic profiles and receptor binding characteristics 1
• Avoid opioids or butalbital-containing compounds for acute migraine treatment, as they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time 1
• Ensure early administration of any acute medication, as they are most effective when taken early in the attack while headache is still mild 1