What is the next step for a patient with migraines who continues to experience headaches on sumatriptan (Imitrex) 50 milligrams?

From the Guidelines

For a patient with migraines who continues to have headaches on sumatriptan 50 mg, the next step would be to consider adding an NSAID or acetaminophen to the treatment regimen, as the current guideline from the American College of Physicians suggests that adding a triptan to an NSAID or acetaminophen can be effective for patients who do not achieve sufficient pain relief with a single medication 1. When considering the addition of an NSAID or acetaminophen, it is essential to ensure that the patient is not exceeding the recommended maximum daily dose. The choice of a specific NSAID (such as aspirin, celecoxib, diclofenac, ibuprofen, or naproxen) or the decision to use acetaminophen should be based on individualized decision making, taking into consideration patient preferences and factors such as route of administration and cost 1. Some key points to consider in the management of migraines include:

• Ensuring the use of the appropriate dosage of the current medication and considering an increase if necessary, without exceeding the recommended maximum daily dose.
• Being aware that patients who do not tolerate or have an inadequate response to a recommended migraine treatment may respond to another within the same drug class.
• Considering the use of CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen 1.
• Avoiding the use of opioids or butalbital for the treatment of acute episodic migraine, as they are not recommended due to their potential for dependence and other adverse effects. It is crucial to tailor the treatment approach to the individual patient, considering factors such as the severity of their migraines, response to previous treatments, and any comorbid conditions or preferences they may have.

From the FDA Drug Label

The recommended dose of sumatriptan tablets is 25 mg, 50 mg, or 100 mg. Doses of 50 mg and 100 mg may provide a greater effect than the 25 mg dose, but doses of 100 mg may not provide a greater effect than the 50 mg dose. If the migraine has not resolved by 2 hours after taking sumatriptan tablets, or returns after a transient improvement, a second dose may be administered at least 2 hours after the first dose.

The next step for a patient with migraines who continues to have headaches on sumatriptan 50 mg is to:

• Consider administering a second dose of sumatriptan at least 2 hours after the first dose, as the migraine has not resolved or has returned after a transient improvement.
• Alternatively, the dose can be increased to 100 mg, as doses of 50 mg and 100 mg may provide a greater effect than the 50 mg dose, but this should be done with caution due to the potential for increased adverse reactions 2.

From the Research

Treatment Options for Migraines

• For a patient with migraines who continues to have headaches on sumatriptan 50 mg, the next step could be to increase the dose to 100 mg, as studies have shown that sumatriptan 100 mg is more effective than 50 mg for pain-free response at 2 hours 3, 4.
• Another option could be to add naproxen to the treatment regimen, as the combination of sumatriptan and naproxen has been shown to be effective in the acute treatment of migraine headaches 5.
• The patient could also be switched to a different triptan, such as naratriptan, rizatriptan, or lysine acetylsalicylate plus metoclopramide, as these have been shown to be similarly effective to sumatriptan 6.
• It is also important to consider the timing of treatment, as studies have shown that treating early, during the mild pain phase, can give significantly better results than treating established attacks with moderate or severe pain intensity 4, 5.

Efficacy and Safety of Sumatriptan

• Sumatriptan has been shown to be effective in relieving migraine headache and other symptoms associated with migraine, including nausea, photophobia, and phonophobia 3, 4, 7, 6.
• The incidence of adverse events with sumatriptan is generally low, but can include nausea, vomiting, malaise, and fatigue, as well as injection site reactions with subcutaneous administration 7, 6.
• Serious adverse events, including cardiovascular effects, can occur rarely, and sumatriptan is contraindicated in patients with a history of cardiovascular disease 6.

Dosing and Administration

• The optimal dose of sumatriptan for the acute treatment of migraine has not been fully established, but studies suggest that 50 mg and 100 mg are more effective than 25 mg 3, 7.
• Sumatriptan can be administered orally, subcutaneously, intranasally, or rectally, and the choice of route will depend on the individual patient's needs and preferences 6.