What are the recommended acute migraine dosing options for sumatriptan in a healthy adult, and what are its contraindications and alternative therapies?

Sumatriptan for Acute Migraine Treatment

Recommended Dosing Options

For acute migraine in healthy adults, start with sumatriptan 50 mg orally at headache onset; if inadequate response after 2–3 attacks, escalate to 100 mg. 1, 2, 3

Oral Dosing Algorithm

• Initial dose: 50 mg provides total or partial benefit in 70% of patients within 2 hours for both moderate and severe attacks, with fewer adverse events than 100 mg. 4
• Escalation: If 50 mg fails after 2–3 migraine episodes, increase to 100 mg, which achieves pain-free response in approximately 30% and headache relief in 50–73% of patients at 2 hours. 2, 5, 6
• Lower dose: 25 mg is less effective (NNT 7.5 for pain-free response) and should be reserved for patients who cannot tolerate higher doses. 5
• Second dose: May be taken if some response to the first dose occurred, separated by at least 2 hours; maximum 200 mg in 24 hours. 3

Alternative Routes for Severe Attacks

• Subcutaneous 6 mg provides the highest efficacy (70–82% response within 1 hour, onset in 10–15 minutes) and is preferred for rapid-onset attacks or when nausea/vomiting prevents oral absorption. 1, 2, 7, 6
• Intranasal 5–20 mg is effective when significant nausea or vomiting is present, achieving 70–80% response within 1 hour. 1, 6

Timing and Combination Therapy

• Take early: Sumatriptan is most effective when administered while pain is still mild, achieving approximately 50% pain-free response at 2 hours versus 28% when delayed until pain is moderate-to-severe. 1
• Combination with NSAID: Adding naproxen 500 mg to sumatriptan 50–100 mg provides superior efficacy (NNT 3.5 for headache relief at 2 hours) compared to either agent alone. 1, 2

Absolute Contraindications

Sumatriptan is contraindicated in patients with ischemic vascular disease, uncontrolled hypertension, or recent use of ergotamines or other triptans. 8, 3

• Cardiovascular: History of coronary artery disease, myocardial infarction, coronary artery vasospasm, Wolff-Parkinson-White syndrome, or other cardiac accessory conduction pathway disorders. 8, 3
• Cerebrovascular: History of stroke, transient ischemic attack, hemiplegic migraine, or basilar migraine. 8, 3
• Vascular: Peripheral vascular disease or ischemic bowel disease. 3
• Hypertension: Uncontrolled hypertension (controlled hypertension is not a contraindication). 8, 3
• Drug interactions: Use within 24 hours of another 5-HT₁ agonist (triptan) or ergotamine-containing medication; concurrent or recent (past 2 weeks) use of MAO-A inhibitor. 8, 3
• Hepatic impairment: Severe hepatic impairment (maximum 50 mg single dose in mild-to-moderate impairment). 8, 3
• Hypersensitivity: Known hypersensitivity to sumatriptan (angioedema and anaphylaxis reported). 3

Special Populations

• Pregnancy: May cause fetal harm based on animal data; use only under strict specialist supervision. 8
• Children with high-risk features: Avoid in children with hemiplegic migraine, basilar migraine, known vascular risk factors, or prior cardiac or cerebral ischemia. 8

Common Adverse Effects

• Sensory: Paresthesia (numbness/tingling in extremities, fingers, toes, face) occurs frequently but is usually mild and transient. 8
• Cardiovascular: Chest pressure, tightness, heaviness, or warmth (3–5% of patients); palpitations; these are generally not associated with myocardial ischemia but warrant cardiac evaluation in high-risk patients. 8, 3
• Pain/pressure sensations: Neck, throat, or jaw pain/tightness/pressure; feelings of warmth or cold. 8, 3
• Gastrointestinal: Nausea, vomiting, dry mouth (xerostomia). 8
• General: Malaise, vertigo, fatigue. 8, 3

Critical Frequency Limitation

Limit sumatriptan use to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 2, 3

• If acute treatment is required more than twice weekly, initiate preventive therapy immediately (propranolol 80–240 mg/day, topiramate, or amitriptyline 30–150 mg/day). 1, 2

Alternative Therapies When Sumatriptan Fails or Is Contraindicated

First-Line Alternatives: Try Different Triptans

Failure of one triptan does not predict failure of others; try rizatriptan 10 mg (fastest oral triptan, peak 60–90 min) or eletriptan 40 mg (superior efficacy to sumatriptan 100 mg) after 2–3 failed episodes. 1, 2

• Rizatriptan 10 mg: Highest clinical effectiveness rating, faster pain relief, higher pain-free rates at 2 hours. 2
• Eletriptan 40–80 mg: 68% headache response and 38% pain-free at 2 hours with 80 mg dose. 2
• Naratriptan 2.5 mg: Longest half-life, may reduce recurrence but lower efficacy. 2
• Almotriptan 12.5 mg: Better tolerability with maintained efficacy. 2

Second-Line: CGRP Antagonists (Gepants)

Ubrogepant 50–100 mg or rimegepant are recommended as third-line options after failure of triptan + NSAID combinations; they have no vasoconstriction and are safe in cardiovascular disease. 1

• Limit to ≤8 migraine attacks per 30 days to prevent medication-overuse headache. 1

Third-Line: Ditans

Lasmiditan 50–200 mg (5-HT₁F agonist) is safe in cardiovascular disease but requires an 8-hour driving restriction due to CNS effects (dizziness, somnolence). 1

Parenteral Options for Severe Attacks

• Dihydroergotamine (DHE) 0.5–1.0 mg IV or intranasal: Good evidence for efficacy as monotherapy; contraindicated with concurrent triptan use (within 24 hours), beta-blockers, uncontrolled hypertension, coronary artery disease, pregnancy, or sepsis. 1
• Ketorolac 30 mg IV + metoclopramide 10 mg IV: First-line combination for severe migraine requiring IV treatment, with rapid onset and minimal rebound headache risk. 1

Medications to Absolutely Avoid

Never use opioids (hydrocodone, oxycodone, morphine, codeine, tramadol) or butalbital-containing compounds for migraine; they provide questionable efficacy, cause dependency, precipitate rebound headaches, and worsen long-term outcomes. 1

Common Pitfalls

• Do not abandon triptan therapy after a single failed attempt—try a different triptan or route before escalating to gepants or ditans. 1, 2
• Do not delay treatment—early administration (while pain is mild) doubles the pain-free response rate. 1
• Do not use sumatriptan and ergotamines within 24 hours of each other due to additive vasoconstrictive effects. 2, 3
• Do not increase frequency of acute medication use in response to treatment failure; instead, transition to preventive therapy. 1