What is sumatriptan indicated for?

Sumatriptan: Indications and Clinical Use

Primary Indication

Sumatriptan is indicated for the acute treatment of migraine headache with or without aura in adults. 1

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Position in Migraine Treatment Algorithm

• First-line therapy consists of NSAIDs (ibuprofen 400–800 mg, naproxen 500–825 mg, or aspirin 1000 mg) for mild-to-moderate migraine attacks. 2, 3

• Sumatriptan is recommended as second-line therapy for moderate-to-severe migraine attacks or when NSAIDs provide inadequate relief after 2–3 episodes. 4

• Combination therapy of sumatriptan plus an NSAID (naproxen 500 mg) is superior to either agent alone, achieving 130 additional patients per 1,000 with sustained pain relief at 48 hours and 90 additional patients per 1,000 with pain relief at 2 hours compared to sumatriptan monotherapy. 2

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Mechanism of Action

• Sumatriptan is a selective serotonin 5-HT₁B/1D receptor agonist that mediates vasoconstriction of dilated cranial blood vessels and inhibits the release of inflammatory neuropeptides from perivascular trigeminal nerve terminals in the dura mater. 5, 6

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Dosing and Route Selection

Oral Sumatriptan

• Standard dose: 50–100 mg at migraine onset when headache is still mild, not during the aura phase. 4, 7
• Oral sumatriptan achieves headache relief in 50–67% of patients at 2 hours versus 10–31% with placebo. 6

Subcutaneous Sumatriptan

• Dose: 6 mg subcutaneously for severe attacks, rapid progression to peak intensity, or when severe nausea/vomiting prevents oral administration. 3, 4
• Subcutaneous sumatriptan provides the highest efficacy among all triptan formulations, achieving complete pain relief in approximately 59% of patients by 2 hours with onset within 15 minutes. 3, 7
• Headache relief at 1 hour occurs in 70–80% of patients receiving subcutaneous sumatriptan 6 mg versus 18–26% with placebo. 6

Intranasal Sumatriptan

• Dose: 5–20 mg intranasally when oral administration is compromised by nausea or vomiting. 3, 7

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Optimal Timing

• Take sumatriptan early in the attack when pain is still mild for maximum effectiveness; approximately 50% of patients become pain-free at 2 hours when treated early versus 28% when treatment is delayed until pain is moderate or severe. 2, 4

• Do not administer during the aura phase, as triptans are ineffective when given during aura. 7

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Critical Contraindications

• Ischemic heart disease, previous myocardial infarction, or coronary artery vasospasm (including Prinzmetal angina). 3, 5

• Uncontrolled hypertension. 7, 5

• Cerebrovascular disease, history of stroke or transient ischemic attack. 3

• Peripheral vascular disease. 7

• Basilar or hemiplegic migraine. 3, 5

• Concurrent use with ergotamines or MAO inhibitors (do not use within 24 hours of each other due to additive vasoconstrictive effects). 4, 5

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Managing Treatment Failure

• If one triptan fails after 2–3 headache episodes, try a different triptan, as failure of one does not predict failure of others. 3, 4

• Alternative oral triptans include rizatriptan 10 mg (fastest oral triptan, reaching peak concentration in 60–90 minutes), eletriptan 40 mg, or zolmitriptan 2.5–5 mg. 3

• If all oral triptans fail, escalate to subcutaneous sumatriptan 6 mg. 3, 4

• If all triptans fail after adequate trials, escalate to CGRP antagonists (ubrogepant, rimegepant, or zavegepant). 3

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Headache Recurrence

• Approximately 40% of patients who initially respond to sumatriptan experience headache recurrence within 24 hours. 5, 6

• Combining sumatriptan with a fast-acting NSAID reduces recurrence rates, but repeating treatment increases the risk of medication-overuse headache. 4

• Most patients who experience recurrence respond well to a second dose of sumatriptan. 6, 8

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Medication-Overuse Headache Prevention

• Strictly 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. 2, 4, 7

• If acute treatment is needed more than twice weekly, initiate preventive therapy immediately rather than increasing acute medication frequency. 2, 7

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Adjunctive Therapy

• For patients with significant nausea, add metoclopramide 10 mg or domperidone 20–30 minutes before sumatriptan, as antiemetics provide synergistic analgesia beyond treating nausea alone. 4

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What Sumatriptan Is NOT Indicated For

• Sumatriptan is not indicated for migraine prevention. 1

• Safety and effectiveness have not been established for cluster headache (FDA label), although subcutaneous sumatriptan 6 mg achieved headache relief within 15 minutes in 74–75% of cluster headache patients in clinical trials. 1, 6

• If a patient has no response to the first migraine attack treated with sumatriptan, reconsider the diagnosis of migraine before administering it for subsequent attacks. 1

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Comparative Efficacy

• Oral sumatriptan 100 mg consistently achieved significantly greater response rates than ergotamine 2 mg plus caffeine 200 mg (66% vs 48% for first attack). 6

• Oral sumatriptan 100 mg was more effective than aspirin 900 mg plus metoclopramide 10 mg. 6

• Subcutaneous sumatriptan 6 mg was significantly more effective than intranasal dihydroergotamine mesylate 1 mg. 9

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Common Adverse Effects

• Oral sumatriptan: nausea, vomiting, malaise, fatigue, dizziness. 5, 6

• Subcutaneous sumatriptan: injection site reactions (minor pain and redness) occur in approximately 30–40% of patients, although incidence is markedly reduced with auto-injector self-administration. 5, 6

• Chest symptoms (tightness and pressure) occur in 3–5% of patients but have been associated with myocardial ischemia only in rare isolated cases. 5, 6

• Most adverse events are transient and mild. 5, 6