What is the proper usage of Sumatriptan (Imitrex) 5mg nasal spray for an adult patient with a history of migraines?

Sumatriptan 5mg Nasal Spray Administration for Migraine

Administer one spray (5mg) in a single nostril at the onset of migraine symptoms, which can be repeated once after 2 hours if needed, with a maximum of 40mg (two 20mg doses or equivalent) in 24 hours. 1

Optimal Timing and Dosing Strategy

• Take sumatriptan as early as possible when migraine symptoms begin, ideally when pain is still mild, for maximum effectiveness. 2, 1
• The 5mg dose is the lowest available intranasal formulation; clinical trials demonstrate that the 20mg dose provides superior efficacy compared to lower doses (5mg, 10mg), with onset of relief as early as 15 minutes post-dose. 3, 4
• If the 5mg dose provides insufficient relief after trying it for 2-3 migraine episodes, consider switching to the 10mg or 20mg intranasal dose, or trying a different triptan, as failure of one dose does not predict failure of higher doses or alternative triptans. 2, 1

Administration Technique

• Deliver the spray into one nostril only—studies show that dividing the dose between both nostrils confers no advantage over single-nostril administration. 4
• The device delivers the medication in a 0.1ml aqueous solution. 4
• Expect a bitter or unpleasant taste, which is the most common adverse event but is generally well-tolerated. 3, 4

Repeat Dosing and Frequency Limits

• If headache returns or does not fully resolve, you may administer a second dose after a minimum of 2 hours, not to exceed 40mg total in 24 hours. 1
• Critical frequency limitation: Restrict sumatriptan use to no more than 2 days per week (10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 2, 1

When to Consider Alternative Approaches

• If nausea and vomiting are severe, intranasal sumatriptan is particularly useful as it bypasses the need for oral medication. 2, 3
• Combination therapy with an NSAID (naproxen 500mg or ibuprofen 400-800mg) taken simultaneously with sumatriptan provides superior efficacy compared to either agent alone and should be considered for moderate to severe attacks. 2
• If the 5mg dose fails after 2-3 attacks, escalate to higher intranasal doses (10mg or 20mg) before abandoning intranasal sumatriptan entirely. 1, 4
• For patients requiring faster relief, subcutaneous sumatriptan 6mg provides the highest efficacy (59% pain-free at 2 hours) with onset within 15 minutes, though with higher adverse event rates. 2, 5

Absolute Contraindications

• Do not use sumatriptan if you have coronary artery disease, previous myocardial infarction, Prinzmetal angina, uncontrolled hypertension, hemiplegic migraine, or basilar migraine. 1
• Do not use within 24 hours of another triptan or ergotamine/dihydroergotamine (DHE) in either direction—a mandatory washout period is required. 1
• Do not use if currently taking MAOIs (monoamine oxidase inhibitors). 1

Expected Adverse Effects

• Cardiovascular sensations such as chest pressure, heaviness, or warmth occur in 3-5% of patients and are generally benign but warrant evaluation if severe or persistent. 1
• Bitter, bad, or unpleasant taste is the most common adverse event with intranasal formulations but does not differ significantly from placebo in terms of other adverse events. 3, 4

Common Pitfall to Avoid

• Do not wait until pain becomes severe—sumatriptan works best when taken early in the attack while pain is still mild, as delayed administration significantly reduces efficacy. 2, 1
• Do not increase frequency of use beyond 2 days per week—if you need acute treatment more frequently, initiate preventive migraine therapy immediately rather than increasing acute medication use, which creates a vicious cycle of medication-overuse headache. 2