What are the recommended doses of sumatriptan (oral tablets, nasal spray, and subcutaneous injection) for acute migraine in adults and adolescents?

Sumatriptan Dosing for Acute Migraine

Sumatriptan is available in three formulations with distinct dosing: oral tablets 50–100 mg (maximum 200 mg/24 hours), subcutaneous injection 6 mg (maximum 12 mg/24 hours), and intranasal spray 5–20 mg (maximum 40 mg/24 hours), with route selection based on attack severity and presence of nausea. 1

Route-Specific Dosing Recommendations

Oral Tablets

• Start with 50–100 mg at migraine onset when pain is still mild, as early treatment significantly improves outcomes (≈50% pain-free at 2 hours versus ≈28% when delayed). 2
• May repeat once after 2 hours if headache returns or does not fully resolve, but do not exceed 200 mg in 24 hours. 1
• Oral sumatriptan achieves headache relief in 50–73% of patients within 2 hours at the 100 mg dose. 3, 4
• The 100 mg dose has a number-needed-to-treat (NNT) of 3.4 for headache relief at 2 hours, while the 50 mg dose has an NNT of 3.2. 4

Subcutaneous Injection

• Administer 6 mg subcutaneously at migraine onset for the fastest and most effective relief, particularly when rapid progression to peak intensity occurs or when significant nausea/vomiting is present. 2, 1
• May repeat once after 1 hour if needed, with a maximum of 12 mg per 24 hours. 1
• Subcutaneous sumatriptan provides the highest efficacy among all triptan formulations, achieving relief in 70–82% of patients within 15 minutes and complete pain relief in approximately 59% by 2 hours. 2, 3, 5

Intranasal Spray

• Administer 5–20 mg intranasally at migraine onset, with the 20 mg dose preferred for moderate-to-severe attacks. 1, 6
• May repeat after 2 hours if needed, with a maximum of 40 mg per 24 hours. 1
• The 20 mg intranasal dose reduces moderate or severe pain to mild or none in 62–63% of patients at 2 hours, with onset of relief as early as 15 minutes. 6
• Intranasal sumatriptan is particularly useful when significant nausea or vomiting precludes oral medication. 2, 6

Adolescent Dosing (Ages 12–17)

• Intranasal spray 5–20 mg is the only FDA-approved formulation for adolescents, with the same maximum daily dose of 40 mg/24 hours as adults. 1
• Oral and subcutaneous formulations are not FDA-approved for patients under 18 years of age. 1

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. 2, 1
• If acute treatment is required more than twice weekly, initiate preventive therapy immediately rather than increasing sumatriptan frequency. 2

Managing Inadequate Response

• Trial sumatriptan for 2–3 separate headache episodes before determining effectiveness, as response can vary between attacks. 1
• If 100 mg oral sumatriptan provides insufficient relief, add an NSAID (naproxen 500 mg, ibuprofen 400–800 mg) rather than increasing triptan dose or frequency, as combination therapy is superior to either agent alone. 2, 1
• If sumatriptan fails after adequate trials, switch to a different triptan (rizatriptan, eletriptan, zolmitriptan, naratriptan), as failure of one triptan does not predict failure of others. 2, 1

Headache Recurrence Management

• Approximately 40% of patients experience headache recurrence within 8–24 hours after initial response, which can be effectively treated with a second dose following the minimum interval requirements (2 hours for oral, 1 hour for subcutaneous, 2 hours for intranasal). 1, 3, 5

Absolute Contraindications

• Ischemic heart disease, previous myocardial infarction, or Prinzmetal angina, as sumatriptan causes vasoconstriction. 1, 5
• Uncontrolled hypertension (controlled hypertension is not a contraindication). 1, 7, 5
• Hemiplegic or basilar migraine. 1, 7, 5
• Use within 24 hours of ergotamine-containing medications or another triptan, due to additive vasoconstrictive effects. 1, 7
• Current MAOI use or within 2 weeks of discontinuation. 1, 7
• Cerebrovascular disease, history of stroke or TIA. 2

Common Adverse Effects

• Cardiovascular sensations (chest pressure, heaviness, warmth) occur in 3–5% of patients and are usually benign but require evaluation if persistent. 1, 7
• Gastrointestinal effects including nausea, vomiting, and dry mouth. 7
• Numbness and tingling in extremities (fingers, toes, face) are frequently reported but usually mild. 7
• Intranasal formulation: bad, bitter, or unpleasant taste is the most common adverse event. 6
• Minor adverse events occur more commonly with sumatriptan 100 mg than placebo (NNH = 7.1), but are generally transient and well-tolerated. 4

Special Populations

• Pregnancy: Use only under strict specialist supervision, as safety data are limited. 7
• Hepatic impairment: Contraindicated in patients with impaired hepatic function. 7
• Parkinson's disease on MAO-B inhibitors: Sumatriptan is contraindicated; use NSAIDs, acetaminophen, or CGRP antagonists (rimegepant, ubrogepant) instead. 1