Sumatriptan for migraine

What sumatriptan is

Sumatriptan is a serotonin (5-HT1B/1D) receptor agonist, or triptan. US labels indicate it for acute treatment of migraine with or without aura in adults, once migraine has been clearly diagnosed. It is not indicated for preventing attacks. Approval, brands and forms differ by country; this page uses US labels.

Forms

• Tablets (Imitrex and generics).
• Injection (Imitrex). This is the form also indicated for acute cluster headache in adults. The tablet and nasal spray labels state that safety and effectiveness in cluster headache have not been established.
• Nasal spray (Imitrex, Tosymra). The Tosymra label bases efficacy on bioavailability compared with a sumatriptan injection, not on its own migraine trials.
• Nasal powder (Onzetra Xsail), used with a breath-powered device.

The dose differs by form and comes from the label or the prescriber.

Results at 2 hours

Labels report headache response: moderate or severe pain reduced to mild or none. Ranges cover all doses tested, so they do not describe any single dose. The forms were tested in separate trials, not against each other.

Form	Trials	Sumatriptan	Placebo
Tablets	3	50–62%	17–27%
Injection	2	81–82%	31–39%
Nasal spray	5	43–64%	25–36%
Nasal powder	1	68%	45%

A Cochrane overview (Derry 2014, 52,236 participants) reports pain freedom at 2 hours of 59% with one injected dose against 15% with placebo, and 28% with one tablet dose against 11%.

Contraindications and warnings

The Imitrex tablets label says sumatriptan must not be used with:

• ischemic coronary artery disease or coronary vasospasm, including Prinzmetal’s angina;
• Wolff-Parkinson-White syndrome or similar accessory-pathway arrhythmias;
• a history of stroke, transient ischemic attack, or hemiplegic or basilar migraine;
• peripheral vascular disease, ischemic bowel disease, or uncontrolled hypertension;
• severe liver impairment;
• another triptan or an ergot-type medicine within 24 hours;
• an MAO-A inhibitor now or within the past 2 weeks;
• hypersensitivity to sumatriptan.

Label warnings include heart attack, arrhythmia, chest, throat or jaw tightness, stroke, reduced blood flow to the bowel or limbs, serotonin syndrome, raised blood pressure, anaphylaxis and seizures. The label names SSRIs, SNRIs, tricyclic antidepressants and MAO inhibitors as the medicines with which serotonin syndrome particularly occurs. Nasal forms add local effects: bad taste on the Imitrex spray label and local irritation in about 46% of patients on the Tosymra label.

Monthly limit

ICHD-3 sets the limit for triptans, in any form, at 10 or more days a month for more than 3 months. The Imitrex label gives the same 10-day figure in its medication-overuse warning. ICHD-3 adds that triptan overuse may raise attack frequency to that of chronic migraine. Check your count with the medication days counter.

In a headache diary

Record the form as well as the name, because the table above differs by form. Note the time of the dose and the pain 2 hours later: none, mild, or moderate to severe. If you carry both tablets and injection, days with either form add up to one triptan count.