Maximum Monthly Sumatriptan Tablet Use for Migraine
Sumatriptan tablets should be limited to no more than 8–10 treatment days per month to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 2
FDA-Approved Dosing Limits
The FDA label states that the safety of treating an average of more than 4 headaches in a 30-day period has not been established for sumatriptan tablets. 2
The maximum daily dose is 200 mg in any 24-hour period, with individual doses of 25 mg, 50 mg, or 100 mg. 2
If a migraine returns after initial improvement, a second dose may be taken at least 2 hours after the first dose, but total intake must not exceed 200 mg per day. 2
Critical Frequency Limitation to Prevent Medication-Overuse Headache
All acute migraine medications, including sumatriptan, must be restricted to ≤2 days per week (approximately 10 days per month) to avoid medication-overuse headache (MOH). 1, 3
Triptans carry a lower threshold for MOH than NSAIDs: using triptans on ≥10 days per month triggers MOH, whereas NSAIDs require ≥15 days per month. 1
Medication-overuse headache creates a self-perpetuating cycle where frequent triptan use paradoxically increases headache frequency, potentially converting episodic migraine into chronic daily headache. 1, 3
When to Initiate Preventive Therapy
If you require sumatriptan more than twice weekly, preventive therapy must be initiated immediately rather than increasing acute medication frequency. 1
Preventive therapy is indicated for patients experiencing ≥2 migraine attacks per month producing disability lasting ≥3 days, or when acute medication use exceeds the 2-days-per-week threshold. 1
First-line preventive options include beta-blockers (propranolol 80–240 mg/day), topiramate, or amitriptyline 30–150 mg/day. 1
Optimizing Sumatriptan Efficacy Within Safe Limits
Treat early when pain is still mild rather than waiting for moderate-to-severe pain: approximately 50% of patients become pain-free at 2 hours when treating early versus only 28% when delaying treatment. 1
Combination therapy with sumatriptan plus an NSAID (naproxen 500 mg) is superior to either agent alone, with 130 additional patients per 1,000 achieving sustained pain relief at 48 hours. 1
If sumatriptan provides inadequate relief after 2–3 headache episodes, switch to a different triptan (rizatriptan, eletriptan, zolmitriptan) rather than increasing frequency, because failure of one triptan does not predict failure of others. 1, 3
Common Prescribing Pitfall
- Do not allow patients to increase sumatriptan frequency in response to treatment failure—this creates the vicious cycle of MOH. Instead, optimize acute treatment strategy (add NSAID, switch triptans, treat early) while transitioning to preventive therapy. 1