Maximum Effective Dose of Tryptomer (Sumatriptan) for Cluster Headache
Subcutaneous sumatriptan 6 mg is the maximum recommended dose for acute treatment of cluster headache, and higher doses (12 mg) provide no additional benefit while increasing adverse events. 1
Evidence-Based Dosing
The 2024 VA/DoD guidelines recommend subcutaneous sumatriptan 6 mg as the standard dose for short-term treatment of cluster headache attacks. 1
A dose-comparison trial demonstrated that while 12 mg subcutaneous sumatriptan achieved headache relief in 80% of patients at 15 minutes versus 75% with 6 mg, this difference was not statistically significant, and the 12 mg dose produced significantly more adverse events. 2
The 6 mg subcutaneous dose achieves headache relief within 15 minutes in 74–75% of patients with cluster headache, compared to only 26–35% with placebo. 2, 3
Lower-Dose Efficacy
Some patients may respond to doses lower than 6 mg: in an open-label study, 74% of patients reported efficacy with 3 mg subcutaneous sumatriptan and 89% with 2 mg. 4
Lower doses (2–3 mg) produced fewer side effects—only 50% of patients reported adverse events with 2 mg (none severe) compared to 79% with 6 mg (29% severe). 4
Individual patients should trial lower doses (2–3 mg) if they experience significant side effects with 6 mg, as many will maintain therapeutic benefit with reduced adverse events. 4
Route of Administration
Subcutaneous administration is essential for cluster headache—oral triptans lack sufficient evidence for acute cluster headache treatment and should not be used. 1, 5
Intranasal zolmitriptan 10 mg is the only alternative triptan formulation with guideline support for cluster headache, though subcutaneous sumatriptan remains more effective. 1
Critical Safety Limits
Sumatriptan is contraindicated in patients with ischemic heart disease, previous myocardial infarction, Prinzmetal angina, uncontrolled hypertension, cerebrovascular disease, or basilar/hemiplegic migraine. 6, 3
Do not administer sumatriptan within 24 hours of ergotamine-containing medications or another triptan due to additive vasoconstrictive effects. 7, 6
Limit sumatriptan use to no more than 2 days per week to prevent medication-overuse headache. 1, 8
Common Adverse Events
Injection-site reactions (pain, redness) occur in approximately 30–40% of patients but are typically mild and brief. 6, 3
Chest pressure, tightness, or heaviness occurs in 3–5% of patients and is usually benign, though rare cases of myocardial ischemia have been reported. 7, 6
Other common effects include nausea, malaise, vertigo, and neck/throat/jaw discomfort. 7
Clinical Algorithm
Start with subcutaneous sumatriptan 6 mg at the onset of a cluster headache attack. 1, 2
If significant side effects occur, trial 2–3 mg subcutaneous sumatriptan for subsequent attacks, as many patients maintain efficacy with reduced adverse events. 4
Do not exceed 6 mg per attack—the 12 mg dose offers no additional benefit and increases side effects. 2
Maximum frequency: Use no more than 2 days per week to avoid medication-overuse headache. 1, 8
If subcutaneous sumatriptan is ineffective or contraindicated, consider intranasal zolmitriptan 10 mg or normobaric oxygen therapy. 1