Sumatriptan Dosing and Treatment Approach for Migraine
For acute migraine treatment, start with sumatriptan 50-100 mg orally at the earliest sign of headache while pain is still mild, with the 100 mg dose providing superior efficacy (80% pain-free at 2 hours) compared to 50 mg, though both are significantly more effective than 25 mg. 1, 2, 3
Route Selection Based on Clinical Presentation
Subcutaneous sumatriptan 6 mg is the most effective formulation, achieving 70-82% response rates within 15 minutes and 59% complete pain relief by 2 hours—the highest efficacy among all triptan routes. 1, 4, 5 This route should be prioritized for:
- Patients with rapid progression to peak headache intensity 4
- Severe attacks with significant nausea or vomiting 1, 5
- Previous inadequate response to oral formulations 5
Maximum subcutaneous dosing: 6 mg initially, may repeat once after 1 hour if needed, with a maximum of 12 mg per 24 hours. 1, 5, 2
Intranasal sumatriptan 5-20 mg provides an intermediate option when oral route is compromised by nausea but injection is undesirable. 1, 5 May repeat after 2 hours to a maximum of 40 mg per 24 hours. 1, 5
Oral Dosing Strategy
Start with 100 mg for moderate-to-severe migraine rather than 50 mg, as the 100 mg dose demonstrates superior pain-free response (NNT 5.1 vs no significant difference for 50 mg in some studies) and patient preference (35% preferred 100 mg vs 31% for 50 mg). 6, 7
For mild-to-moderate migraine, 50 mg is reasonable, but if inadequate response occurs after 2-3 attacks, escalate to 100 mg rather than accepting suboptimal relief. 2, 3
Timing is critical: Administer at the earliest sign of pain while still mild, before central sensitization develops. 4, 3 Taking sumatriptan during aura phase is contraindicated. 8
If headache persists or returns after 2 hours, a second dose may be given with at least 2 hours between doses, maximum 200 mg per 24 hours. 1, 2
Combination Therapy for Enhanced Efficacy
Add an NSAID (naproxen 500 mg, ibuprofen 400-800 mg, or diclofenac) to sumatriptan rather than increasing triptan dose or frequency if initial response is inadequate. 4 This combination is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours. 4
Do not increase sumatriptan frequency—if 100 mg provides insufficient relief, add NSAID rather than taking additional triptan doses. 4, 5
Managing Treatment Failure
If sumatriptan fails after 2-3 headache episodes, switch to a different triptan (rizatriptan, eletriptan, zolmitriptan, or naratriptan) as failure of one triptan does not predict failure of others. 4, 5
- Rizatriptan 10 mg reaches peak concentration in 60-90 minutes (fastest oral triptan) 4
- Eletriptan 40 mg or zolmitriptan 2.5-5 mg may be more effective with fewer adverse effects 4
- Naratriptan has the longest half-life, potentially decreasing recurrence 4
If all triptans fail, escalate to CGRP antagonists (ubrogepant 50-100 mg or rimegepant) or ditans (lasmiditan 50-200 mg). 4
Headache Recurrence Management
Approximately 40% of patients experience headache recurrence within 8-24 hours after initial response, regardless of route. 8, 9, 6 This can be effectively treated with a second dose following minimum interval requirements (2 hours for oral, 1 hour for subcutaneous). 1, 2
Critical Frequency Limitation
Strictly limit sumatriptan use to no more than 10 days per month (2 days per week) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 4, 5 This threshold is lower than for NSAIDs (15 days/month). 5
If requiring acute treatment more than twice weekly, initiate preventive therapy immediately rather than increasing acute medication frequency. 4, 10
Absolute Contraindications
Sumatriptan must not be administered to patients with: 1, 5, 8
- Coronary artery disease, previous myocardial infarction, or Prinzmetal angina
- Hemiplegic or basilar migraine
- Uncontrolled hypertension
- Current MAOI use
- Use of ergotamine or another triptan within 24 hours
Mandatory 24-hour washout period between sumatriptan and dihydroergotamine (DHE) or other triptans in either direction. 1, 5
Hepatic Impairment Dosing
Maximum single dose should not exceed 50 mg in patients with mild-to-moderate hepatic impairment. 2
Common Adverse Effects
Chest pressure, heaviness, or warmth occurs in 3-5% of patients but has been associated with myocardial ischemia only in rare isolated cases. 1, 8 Other common effects include nausea, vomiting, malaise, fatigue, dizziness, and injection site reactions (30% with subcutaneous route). 1, 8, 6
Special Population: Adolescents
For patients aged 12-17 years, intranasal sumatriptan 5-10 mg is the only FDA-approved triptan formulation, to be used only after NSAIDs fail. 10 First-line treatment should be ibuprofen 400-800 mg or naproxen 500 mg. 10