What is the sumatriptan (Imitrex) dose for acute migraine attacks?

From the Guidelines

The recommended sumatriptan dose for acute migraine attacks is 50-100 mg orally as a single dose, with a maximum daily dose of 200 mg. For subcutaneous injection, the dose is 6 mg, and for nasal spray, 5-20 mg in one nostril. Treatment should be taken at the first sign of migraine headache, but can be effective even if taken later during an attack. If symptoms return after initial relief, a second dose may be taken after 2 hours, but should not exceed the maximum daily dose. Sumatriptan works by stimulating serotonin receptors, causing blood vessel constriction in the brain and reducing inflammation, thereby relieving migraine pain. Common side effects include tingling, flushing, dizziness, and chest tightness. Sumatriptan should be avoided in patients with cardiovascular disease, uncontrolled hypertension, or within 24 hours of using other triptans or ergot medications. For optimal effectiveness, take the medication with water and consider lying down in a dark, quiet room after administration. According to the American College of Physicians guideline 1, the choice of a specific triptan, such as sumatriptan, should be based on individualized decision making, taking into consideration patient preferences on such factors as route of administration and cost. Additionally, the guideline recommends counseling patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy (such as a triptan with an NSAID or acetaminophen) to improve efficacy 1.

Some key points to consider when prescribing sumatriptan include:

• Starting with a low dose and titrating up as needed to minimize side effects
• Avoiding use in patients with a history of cardiovascular disease or uncontrolled hypertension
• Considering alternative treatments, such as NSAIDs or acetaminophen, for patients who do not respond to sumatriptan or have contraindications to its use
• Counseling patients on the potential risks and benefits of sumatriptan, including the risk of medication overuse headache.

It is also important to note that the American College of Physicians guideline 1 recommends against using opioids or butalbital for the treatment of acute episodic migraine, and instead suggests considering alternative options, such as CGRP antagonists or ergot alkaloids, for patients who do not respond to triptans or have contraindications to their use.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Single dose of 25 mg, 50 mg, or 100 mg tablet.(2.1) The recommended dose of sumatriptan tablets is 25 mg, 50 mg, or 100 mg.

The sumatriptan dose for acute migraine attacks is 25 mg, 50 mg, or 100 mg.

• The dose can be repeated after at least 2 hours if some response to the first dose was observed.
• The maximum dose in a 24-hour period is 200 mg.
• In patients with mild to moderate hepatic impairment, the maximum single dose should not exceed 50 mg 2, 2.

From the Research

Sumatriptan Dose for Acute Migraine Attacks

• The recommended dosage of sumatriptan at the onset of migraine symptoms is 100 mg orally or 6 mg subcutaneously 3.
• Studies have shown that sumatriptan 50 mg and 100 mg are effective in relieving migraine headache and associated symptoms, with NNTs of 6.1 and 4.7, respectively, for pain-free at two hours 4.
• The most effective dose of sumatriptan for each route of administration for the outcome of headache relief at two hours was oral 100 mg (NNT 3.5), subcutaneous 6 mg (NNT 2.1), intranasal 20 mg (NNT 3.5), and rectal 25 mg (NNT 2.4) 5.
• Sumatriptan is generally well tolerated, with adverse events being transient and mild, but more common with subcutaneously administered sumatriptan and higher doses of oral and intranasal sumatriptan 6, 5.

Administration Routes and Efficacy

• Subcutaneous administration was the most effective, with pain reduced from moderate or severe to none by two hours in almost 6 in 10 people (59%) taking 6 mg sumatriptan, compared with approximately 1 in 7 (15%) taking placebo 5.
• Oral sumatriptan is effective as an abortive treatment for migraine attacks, relieving pain, nausea, photophobia, phonophobia, and functional disability, but is associated with increased adverse events 4.
• Intranasal and rectal routes of administration also provided clinically useful pain relief, with NNTs of 3.5 and 2.4, respectively, for headache relief at two hours 5.

Combination Therapy

• Sumatriptan plus naproxen is effective in the acute treatment of migraine headaches, with a greater effect than either monotherapy, but additional benefits over sumatriptan alone are not large 7.
• The combination was better than placebo for pain-free and headache relief responses, with NNTs of 3.1 and 4.9, respectively, for pain-free response at two hours 7.