Sumatriptan for Acute Migraine in Adults
Recommended Dosing
For moderate to severe migraine, the American College of Physicians strongly recommends combining sumatriptan with an NSAID (specifically naproxen 500 mg) rather than using sumatriptan alone, as this combination provides superior efficacy with 130 more patients per 1000 achieving sustained pain relief at 48 hours. 1
Oral Sumatriptan Dosing
- Standard dose: 50–100 mg at migraine onset 2
- The 100 mg dose does not provide significantly greater effect than 50 mg, but both are superior to 25 mg 2, 3
- Maximum daily dose: 200 mg total 2
- If headache returns or partial response occurs, may repeat after 2 hours minimum 2
- Hepatic impairment: Maximum single dose should not exceed 50 mg 2
Alternative Routes When Nausea/Vomiting Present
- Subcutaneous: 6 mg provides the highest efficacy—59% achieve complete pain relief by 2 hours (versus 15% with placebo), with onset within 15 minutes 4, 5
- Intranasal: 20 mg dose is most effective, with relief beginning as early as 15 minutes; 62–63% achieve headache relief at 2 hours (versus 29–35% with placebo) 6, 5
- Intranasal 10 mg: Less consistently effective than 20 mg (43–54% response) 6
Critical Frequency Limitation
Limit 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. 1, 5
Contraindications
Sumatriptan is absolutely contraindicated in: 7, 5
- Ischemic heart disease or previous myocardial infarction
- Prinzmetal (variant) angina or coronary artery vasospasm
- Uncontrolled hypertension
- Cerebrovascular disease, history of stroke or TIA
- Basilar or hemiplegic migraine
- Peripheral vascular disease
- Concurrent use with MAO-A inhibitors 2
- Within 24 hours of ergotamine-containing medications or other triptans 7, 5
Side Effects
Common Adverse Events (Mild to Moderate)
The combination of sumatriptan + NSAID results in 90 more adverse events per 1000 treated people compared with placebo, but these are generally mild and transient: 1
- Fatigue, dizziness, nausea 1
- Intranasal route: Bad, bitter, or unpleasant taste (most common) 6
- Subcutaneous route: Injection site reactions in approximately 30% 7
Serious Adverse Events
- Chest symptoms occur in 3–5% of patients but have been associated with myocardial ischemia only in rare isolated cases 7
- Adverse events are more common with subcutaneous administration and higher doses 4
Alternative Options
When Sumatriptan Fails
Try a different triptan first—failure of one triptan does not predict failure of others. 5
Alternative triptans with evidence: 5
- Rizatriptan 10 mg: Fastest oral triptan (peak concentration 60–90 minutes)
- Eletriptan 40 mg or zolmitriptan 2.5–5 mg: Reportedly more effective with fewer adverse reactions than sumatriptan
- Naratriptan: Longest half-life, may decrease recurrence headaches
When All Triptans Fail or Are Contraindicated
CGRP antagonists (gepants) are the primary alternative for patients with cardiovascular contraindications to triptans: 5
- Ubrogepant 50–100 mg (third-line per ACP guidelines) 5
- Rimegepant (also FDA-approved for prevention) 8
- These agents have no vasoconstriction, making them safe in cardiovascular disease 5
Parenteral Options for Severe Attacks
- Dihydroergotamine (DHE) 0.5–1.0 mg IV: Good evidence for efficacy when NSAIDs contraindicated; can repeat hourly up to 2 mg/day 5
- Contraindications: Concurrent triptans within 24 hours, beta-blockers, uncontrolled hypertension, coronary disease, pregnancy, sepsis 5
- Metoclopramide 10 mg IV + ketorolac 30 mg IV: First-line IV combination for severe migraine 5
Medications to Absolutely Avoid
Opioids (hydromorphone, oxycodone, codeine) and butalbital-containing compounds should never be used for migraine—they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time. 5
Optimal Treatment Algorithm
Step 1: Mild to Moderate Migraine
Step 2: Moderate to Severe Migraine or NSAID Failure
- Add sumatriptan 50–100 mg to naproxen 500 mg (strongest recommendation; high-certainty evidence) 1
- This combination is superior to either agent alone with NNT 3.5 for headache relief at 2 hours 5
Step 3: Early Treatment When Pain Is Mild
- Treating early provides significantly better outcomes than waiting until pain is moderate or severe—50% achieve pain-free response at 2 hours (versus 28% when treating moderate/severe pain) 1
Step 4: Significant Nausea/Vomiting Present
- Switch to subcutaneous sumatriptan 6 mg (most effective; onset 15 minutes) or intranasal sumatriptan 20 mg 5, 6, 4
Step 5: Headache Recurrence Within 24 Hours
- Approximately 40% experience recurrence; may repeat sumatriptan dose after minimum 2-hour interval 7, 2
Step 6: Frequent Attacks (>2 Days/Week)
- Initiate preventive therapy immediately—do not increase frequency of acute medication, as this creates medication-overuse headache 1, 5
Critical Pitfalls to Avoid
- Never allow patients to use sumatriptan more than 2 days per week—this creates a vicious cycle of medication-overuse headache 1, 5
- Do not prescribe opioids or butalbital compounds as alternatives when sumatriptan fails—escalate to different triptans or gepants instead 5
- Do not give sumatriptan during migraine aura—wait until headache phase begins 7
- Never combine sumatriptan with ergotamines or other triptans within 24 hours due to additive vasoconstrictive effects 7, 5
- Do not abandon triptan therapy after a single failed attempt—try at least 2–3 headache episodes with each triptan before switching 5