For a patient with migraines, should I use sumitriptan (a serotonin‑1B/1D receptor agonist) for acute attacks or amitriptyline (a tricyclic antidepressant) for preventive therapy?

Sumatriptan vs Amitriptyline: Different Roles in Migraine Management

Sumatriptan and amitriptyline serve fundamentally different purposes in migraine treatment and should not be compared as alternatives—sumatriptan is an acute abortive medication for active migraine attacks, while amitriptyline is a preventive agent to reduce attack frequency. 1, 2

Clinical Decision Algorithm

Use Sumatriptan When:

• The patient is experiencing an active migraine attack requiring immediate relief 1, 3
• The patient has moderate to severe migraine attacks or mild to moderate attacks unresponsive to NSAIDs 1
• Rapid symptom relief is the priority (subcutaneous sumatriptan provides pain relief in 15 minutes, with 59% achieving complete pain freedom by 2 hours) 1, 3

Use Amitriptyline When:

• The patient requires preventive therapy because they experience ≥2 migraine attacks per month producing disability lasting ≥3 days per month 2, 4
• The patient uses acute medications (like sumatriptan) more than twice per week, risking medication overuse headache 2, 4
• Comorbid conditions exist: depression, anxiety, sleep disturbances, or mixed migraine with tension-type headache 2, 4

Sumatriptan: Acute Treatment Details

Route Selection Based on Clinical Scenario

• Subcutaneous 6 mg: Most effective route with fastest onset (15 minutes to peak concentration); 59% achieve complete pain freedom by 2 hours (NNT 2.3); best for severe attacks or when vomiting is present 1, 3
• Oral 50-100 mg: Most commonly used; 28% achieve complete pain freedom by 2 hours with 50 mg dose (NNT 6.1); preferred by most patients 1, 3
• Intranasal 20 mg: Alternative when nausea prevents oral intake but patient refuses injection (NNT 3.5) 1, 3
• Rectal 25 mg: Option for severe nausea/vomiting when injection is refused (NNT 2.4) 1, 3

Critical Prescribing Principles

• Try sumatriptan for 2-3 separate migraine episodes before abandoning therapy, as response can vary between attacks 1
• If one triptan fails, try a different triptan before declaring the class ineffective 1
• Treat early when pain is mild for superior efficacy compared to waiting until pain is moderate or severe 3
• Headache recurrence occurs in 21-57% of patients within 8-12 hours; a second dose is usually effective 1, 5

Contraindications

• Ischemic vascular conditions, vasospastic coronary disease, uncontrolled hypertension, or significant cardiovascular disease 1
• Cannot be used within 24 hours of ergotamine derivatives 1

Amitriptyline: Preventive Treatment Details

Evidence Base and Positioning

• Amitriptyline is a second-line preventive agent (after topiramate, propranolol, and candesartan) with no robust RCT evidence for chronic migraine specifically 2, 4
• Demonstrates efficacy in reducing headache frequency by >50% in approximately 72% of patients with episodic migraine 2
• Superior to propranolol for mixed migraine and tension-type headache, but propranolol is more effective for pure migraine 2, 4

Dosing Strategy

• Start with 10-25 mg at bedtime 2
• Titrate slowly over weeks to months to 30-150 mg/day as tolerated 2
• Maintain therapeutic dose for 2-3 months before assessing efficacy, as premature discontinuation is a common pitfall 2, 4

Side Effects

• Weight gain, drowsiness, anticholinergic symptoms (dry mouth, constipation, urinary retention) 2
• Use with caution in elderly patients due to increased anticholinergic burden, fall risk, and cognitive effects 2

Common Clinical Pitfalls

With Sumatriptan

• Failing to limit use to ≤2 days per week, which leads to medication overuse headache and worsens migraine frequency 2, 4
• Not trying alternative triptans after initial triptan failure 1
• Delaying treatment until pain is severe rather than treating early when pain is mild 3

With Amitriptyline

• Using amitriptyline as first-line for chronic migraine when topiramate has stronger evidence 2, 4
• Discontinuing before 2-3 months at therapeutic dose 2, 4
• Maintaining subtherapeutic doses (<30 mg) indefinitely without titration 2, 4
• Failing to recognize that concurrent frequent sumatriptan use can interfere with preventive therapy effectiveness 2, 4

Integrated Treatment Strategy

Most patients with frequent migraines require both medications: sumatriptan for acute attacks (limited to ≤2 days/week) and amitriptyline for prevention (when attack frequency meets criteria). 1, 2, 4 The goal of preventive therapy is to reduce the need for acute medications, thereby avoiding medication overuse headache while maintaining quality of life. 2, 4