Introduction

Selective serotonin (5-hydroxytryptamine; 5-HT) type 1B and 1D receptor agonist (“triptan”).

Uses for Sumatriptan

Vascular Headaches

Acute treatment of migraine attacks with or without aura.

Sub-Q for acute treatment of cluster headache episodes. Safety and efficacy of oral or intranasal sumatriptan for this use not established.

Not recommended for management of hemiplegic or basilar migraine or for prophylaxis of migraine or cluster headache.

Sumatriptan Dosage and Administration

Administration

Administer orally, intranasally, or by sub-Q injection. Do not administer IM or IV; IV administration may induce coronary vasospasm. Has been administered as an iontophoretic transdermal system; however, marketing was suspended because of serious application site reactions. (See Local Effects under Cautions.)

To achieve maximum relief, initiate therapy as soon as possible after onset of migraine attack.

Oral Administration

Administer sumatriptan tablets orally with fluids; swallow tablet whole.

Administer sumatriptan/naproxen fixed-combination tablets with or without food; do not split, crush, or chew.

Intranasal Administration

Administer intranasally as a single spray into 1 nostril.

Nasal solution unit contains only 1 spray; do not test before use.

To administer, remove unit from package just before use. While sitting down, gently blow nose to clear nasal passages. Keep head in upright position and gently close 1 nostril with index finger; exhale gently through mouth. With other hand, hold unit with thumb supporting at bottom and index and middle fingers on either side of nozzle. Insert nozzle into open nostril about ½ inch. While gently inhaling through nose (with closed mouth), release spray by firmly pressing plunger. Remove nozzle from nostril while keeping head level for 10–20 seconds and gently inhaling through nose and exhaling through mouth; do not inhale deeply. Consult administration instructions provided by manufacturer before use.

Sub-Q Administration

Administer only by sub-Q injection.

Do not administer IM or IV; IV administration may induce coronary vasospasm.

Autoinjection devices are available to facilitate self-administration of 4- or 6-mg dose.

Injection pen for use with prefilled cartridges (each containing a 4- or 6-mg dose): Needle penetrates approximately 5–6 mm (¼ inch); use injection sites with an adequate skin and subcutaneous thickness to accommodate needle length (e.g., lateral thigh, upper arm).

Prefilled injection pen (containing 6-mg dose): Needle projects ¼ inch following activation of device; use injection sites with an adequate skin and subcutaneous thickness to accommodate needle length (e.g., lateral thigh, upper arm).

Prefilled needleless injection device (containing 6-mg dose): Use administration sites on abdomen (avoiding 2-inch area around the umbilicus) or thigh with an adequate subcutaneous thickness to accommodate penetration of the solution into the subcutaneous space. Avoid using administration sites on upper arm, since delivered dose may be suboptimal.

In patients receiving doses other than 4 or 6 mg, only the single-dose vials containing 6 mg/0.5 mL should be used to provide the desired dose.

Dosage

Available as sumatriptan (nasal solution) and sumatriptan succinate (tablets and injection); dosage expressed in terms of sumatriptan.

Following failure to respond to first dose, reconsider diagnosis of migraine prior to administration of a second dose.

Adults

Vascular Headaches

Migraine

25, 50, or 100 mg as a single dose. Individualize dosage selection, weighing the possible benefit (greater effectiveness) and risks (increased adverse effects) of the 50- or 100-mg dose; 100-mg dose may not provide substantially greater effect than 50-mg dose.

If headache recurs or partial response occurs after initial dose, additional oral doses may be administered at intervals of ≥2 hours, up to a maximum oral dosage of 200 mg daily.

If headache recurs after an initial sub-Q dose, additional oral doses may be administered at intervals ≥2 hours, up to a maximum oral dosage of 100 mg daily.

Sumatriptan 85 mg (with naproxen sodium 500 mg) as a single dose.

Efficacy of >1 dose not established. If a second dose is administered, allow ≥2 hours to elapse between the first and second doses.

5, 10, or 20 mg as a single dose; individualize dosage selection, weighing the possible benefit (greater effectiveness) and risks (increased adverse effects) of the 20-mg dose. Doses >20 mg provide no additional benefit.

To achieve a 10-mg dose, administer a single 5-mg dose into each nostril.

If headache recurs, dose may be repeated once after 2 hours, up to a maximum dosage of 40 mg daily.

≤6 mg as a single dose. If dose-limiting adverse effects occur with 6-mg dose, lower doses (e.g., 1–5 mg) may be given.

If headache recurs, a 6-mg sub-Q dose may be repeated once after ≥1 hour or additional oral doses may be administered at intervals ≥2 hours, up to a maximum oral dosage of 100 mg daily.

If patient does not respond to first 6-mg dose, additional doses are unlikely to provide benefit.

Cluster Headache

≤6 mg as a single dose. Manufacturers state that efficacy of doses <6 mg not established; however, some patients may derive benefit from such lower doses (e.g., 3 mg).

If headache recurs, 6-mg dose may be repeated once after ≥1 hour, up to a maximum dosage of 12 mg in any 24-hour period.

If patient does not respond to first 6-mg dose, additional doses are unlikely to provide benefit.

Prescribing Limits

Adults

Vascular Headaches

Migraine

Maximum 200 mg daily; do not exceed 100 mg daily if following an initial sub-Q dose.

Safety of treating an average of >4 headaches per 30-day period has not been established.

Maximum 2 doses (total sumatriptan dosage of 170 mg) in any 24-hour period.

Safety of treating an average of >5 headaches per 30-day period has not been established.

Maximum 40 mg daily.

Safety of treating an average of >4 headaches per 30-day period has not been established.

Maximum 6 mg as a single dose; do not exceed 12 mg (i.e., two 6-mg doses given ≥1 hour apart) in any 24-hour period.

Cluster Headache

Maximum 6 mg as a single dose; do not exceed 12 mg (i.e., two 6-mg doses given ≥1 hour apart) in any 24-hour period.

Special Populations

Hepatic Impairment

Contraindicated in patients with severe hepatic impairment.

Unpredictable increases in bioavailability following oral administration in patients with hepatic impairment. If oral therapy is deemed advisable in these patients, do not exceed 50 mg as a single dose. Avoid use of fixed-combination tablets containing sumatriptan 85 mg and naproxen sodium 500 mg, since sumatriptan dosage cannot be appropriately adjusted.

Geriatric Patients

Select dosage with caution, usually starting at the low end of the dosage range.

Contraindications

• Ischemic heart disease (e.g., angina pectoris, history of MI, documented silent ischemia).

• Coronary artery vasospasm (e.g., Prinzmetal variant angina).

• Wolff-Parkinson-White syndrome or cardiac arrhythmias associated with other accessory pathway conduction disorders.

• Uncontrolled hypertension.

• Other serious underlying cardiovascular disease.

• History of stroke or TIA.

• Peripheral vascular disease or ischemic bowel disease.

• Hemiplegic or basilar migraine.

• Treatment within previous 24 hours with another 5-HT₁ receptor agonist or an ergot alkaloid. (See Specific Drugs under Interactions.)

• Concurrent or recent (within 2 weeks) treatment with an MAO-A inhibitor.

• Severe hepatic impairment.

• Known hypersensitivity to sumatriptan or any ingredient in the formulation.

Warnings/Precautions

Careful Diagnosis of Migraine

Use oral or intranasal sumatriptan only in patients in whom a clear diagnosis of migraine has been established. Use sub-Q sumatriptan only in patients in whom a clear diagnosis of migraine or cluster headache has been established.

If first migraine attack treated with sumatriptan fails to respond to the drug, reconsider diagnosis before administering sumatriptan to treat subsequent attacks.

Exclude other potentially serious neurologic disorders before administering sumatriptan to patients not previously diagnosed with migraine or cluster headache or to those with atypical symptoms.

Cardiac Effects

Possible myocardial ischemia and/or infarction and coronary vasospasm, even in patients without a history of CAD. Contraindicated in patients with ischemic or vasospastic heart disease.

Possible fatal or life-threatening cardiac rhythm disturbances (e.g., ventricular tachycardia or fibrillation). Discontinue if such disturbances occur.

Contraindicated in patients with Wolff-Parkinson-White syndrome or cardiac arrhythmias associated with other accessory pathway conduction disorders.

Tightness, pain, pressure, and heaviness in the precordium, throat, neck, and jaw occur frequently but usually are noncardiac in origin. Manufacturer states that cardiovascular evaluation should be performed if patient is at high cardiac risk.

Patients with symptoms suggestive of angina after receiving sumatriptan should be evaluated for presence of CAD or predisposition to Prinzmetal variant angina before receiving additional doses; if administration resumed and such signs or symptoms recur, ECG evaluation recommended.

Patients at Risk for CAD

Perform cardiovascular evaluation prior to initiating therapy in patients with multiple cardiovascular risk factors (e.g., postmenopausal women; men >40 years of age; patients with risk factors such as hypertension, hypercholesterolemia, smoking, obesity, diabetes, family history of CAD) who have not previously received 5-HT₁ receptor agonist therapy.

If evaluation provides evidence of CAD or coronary vasospasm, do not administer the drug.

If results of evaluation are satisfactory, consider administering the initial dose in a medically supervised setting followed immediately by an ECG.

Periodic cardiovascular evaluation recommended in patients with risk factors for CAD if receiving intermittent long-term therapy.

Cerebrovascular Events

Possible cerebral or subarachnoid hemorrhage and stroke, sometimes fatal. (See Careful Diagnosis of Migraine under Cautions.) Discontinue therapy if a cerebrovascular event occurs.

Risk of certain cerebrovascular events (e.g., stroke, hemorrhage, TIA) may be increased in patients with migraine.

Other Vasospastic Effects

Possible noncoronary vasospastic reactions (e.g., peripheral vascular ischemia, GI ischemia and infarction with abdominal pain and bloody diarrhea, splenic infarction, Raynaud’s syndrome); transient or permanent blindness and partial vision loss reported very rarely in patients receiving 5-HT₁ receptor agonists.

If signs or symptoms suggestive of vasospasm occur following administration, evaluate patient to rule out vasospastic reaction before administering additional doses.

Hypertensive Effects

Substantial increases in BP, including hypertensive crisis with acute impairment of organ systems, reported rarely in patients with or without history of hypertension.

Administer with caution in patients with controlled hypertension as transient increases in BP and peripheral vascular resistance are possible. (See Contraindications under Cautions.)

Monitor BP in all patients receiving the drug.

Serotonin Syndrome

Potentially life-threatening serotonin syndrome reported in patients receiving 5-HT₁ receptor agonists, particularly in those receiving SSRIs or SNRIs concomitantly. (See Specific Drugs under Interactions.) Also may occur in patients receiving MAO inhibitors or tricyclic antidepressants concomitantly.

Symptoms may include mental status changes (e.g., agitation, hallucinations, coma), autonomic instability (e.g., tachycardia, labile BP, hyperthermia), neuromuscular aberrations (e.g., hyperreflexia, incoordination), and/or GI symptoms (e.g., nausea, vomiting, diarrhea).

If manifestations of serotonin syndrome occur, discontinue sumatriptan and any concurrently administered serotonergic agents and initiate supportive and symptomatic treatment.

Medication Overuse Headache

Overuse of drugs indicated for management of acute migraine attacks (e.g., use of 5-HT₁ receptor agonists, ergotamine, opiates, or certain analgesic combinations on a regular basis for ≥10 days per month) may result in migraine-like daily headaches or a marked increase in frequency of migraine attacks.

Detoxification, including withdrawal of overused drugs; treatment of withdrawal symptoms (e.g., transient worsening of headaches); and consideration of prophylactic migraine therapy may be necessary.

Local Effects

Possible transient irritation in nose and throat (e.g., burning, numbness, paresthesia, discharge, pain/soreness), sometimes severe, after intranasal administration; symptoms usually resolve in <2 hours. Effects of extended and repeated use on nasal and/or respiratory mucosa not systematically evaluated.

Burns and scarring reported at application site of sumatriptan iontophoretic transdermal system (Zecuity). Reactions included severe erythema, cracked skin, blistering or welts, burns or scars, skin discoloration, severe pain, pruritus, and burning sensation. Many cases resolved within hours to weeks, but some reactions, typically skin discoloration, were unresolved after several months. Manufacturer voluntarily suspended marketing of the formulation.

Sensitivity Reactions

Hypersensitivity reactions (e.g., anaphylaxis/anaphylactoid reactions), possibly life-threatening or fatal, reported rarely; increased risk in patients with history of sensitivity to multiple allergens.

Seizures

Seizures reported rarely; use with caution in patients with a history of seizures or with conditions associated with a lowered seizure threshold.

Ocular Effects

Corneal opacities and corneal epithelial defects reported in dogs.

Use of Fixed Combinations

When used in fixed combination with naproxen, consider the cautions, precautions, and contraindications associated with naproxen.

Specific Populations

Pregnancy

Category C.

Lactation

Distributed into human milk. Caution advised if sumatriptan is used. Expressing and discarding all milk for 8 hours after receiving a sub-Q dose may minimize exposure to the limited amount of drug distributed into milk. The manufacturers recommend avoiding breast-feeding for 12 hours after receiving sumatriptan oral tablets or nasal spray.

Pediatric Use

Safety and efficacy not established in children <18 years of age; use not recommended. Serious adverse events reported in children receiving sumatriptan.

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults.

Potential for more pronounced increases in BP; consider increased risk for CAD in geriatric patients. (See Cardiac Effects under Cautions.)

Select dosage with caution. Consider the greater frequency of decreased hepatic, renal, and/or cardiac function and of concomitant disease and drug therapy observed in the elderly.

Hepatic Impairment

Contraindicated in patients with severe hepatic impairment.

Due to important role of the liver in presystemic clearance of oral sumatriptan, dosage adjustment recommended if oral therapy is deemed advisable in patients with hepatic impairment. (See Hepatic Impairment under Dosage and Administration.)

Pharmacokinetics of sub-Q sumatriptan not substantially altered in patients with moderate hepatic impairment.

Common Adverse Effects

With oral therapy, pain/pressure sensations in chest/neck/throat/jaw, paresthesia, warm or cold sensation, malaise/fatigue, vertigo.

With intranasal therapy, taste disturbances, nausea, vomiting, disorder/discomfort of nasal cavity or sinuses.

With sub-Q therapy, injection site reaction; atypical sensations (e.g., tingling, warm/hot sensation, burning, feeling of heaviness, pressure, tightness, numbness, paresthesia); dizziness/vertigo; flushing; discomfort of throat, jaw, sinuses, or nasal cavity; weakness, neck pain/stiffness, myalgia; drowsiness/sedation; headache; sweating; chest discomfort (tightness, pressure); nausea and vomiting.

Administration

Administer orally, intranasally, or by sub-Q injection. Do not administer IM or IV; IV administration may induce coronary vasospasm. Has been administered as an iontophoretic transdermal system; however, marketing was suspended because of serious application site reactions. (See Local Effects under Cautions.)

To achieve maximum relief, initiate therapy as soon as possible after onset of migraine attack.

Oral Administration

Administer sumatriptan tablets orally with fluids; swallow tablet whole.

Administer sumatriptan/naproxen fixed-combination tablets with or without food; do not split, crush, or chew.

Intranasal Administration

Administer intranasally as a single spray into 1 nostril.

Nasal solution unit contains only 1 spray; do not test before use.

To administer, remove unit from package just before use. While sitting down, gently blow nose to clear nasal passages. Keep head in upright position and gently close 1 nostril with index finger; exhale gently through mouth. With other hand, hold unit with thumb supporting at bottom and index and middle fingers on either side of nozzle. Insert nozzle into open nostril about ½ inch. While gently inhaling through nose (with closed mouth), release spray by firmly pressing plunger. Remove nozzle from nostril while keeping head level for 10–20 seconds and gently inhaling through nose and exhaling through mouth; do not inhale deeply. Consult administration instructions provided by manufacturer before use.

Sub-Q Administration

Administer only by sub-Q injection.

Do not administer IM or IV; IV administration may induce coronary vasospasm.

Autoinjection devices are available to facilitate self-administration of 4- or 6-mg dose.

Injection pen for use with prefilled cartridges (each containing a 4- or 6-mg dose): Needle penetrates approximately 5–6 mm (¼ inch); use injection sites with an adequate skin and subcutaneous thickness to accommodate needle length (e.g., lateral thigh, upper arm).

Prefilled injection pen (containing 6-mg dose): Needle projects ¼ inch following activation of device; use injection sites with an adequate skin and subcutaneous thickness to accommodate needle length (e.g., lateral thigh, upper arm).

Prefilled needleless injection device (containing 6-mg dose): Use administration sites on abdomen (avoiding 2-inch area around the umbilicus) or thigh with an adequate subcutaneous thickness to accommodate penetration of the solution into the subcutaneous space. Avoid using administration sites on upper arm, since delivered dose may be suboptimal.

In patients receiving doses other than 4 or 6 mg, only the single-dose vials containing 6 mg/0.5 mL should be used to provide the desired dose.

Dosage

Available as sumatriptan (nasal solution) and sumatriptan succinate (tablets and injection); dosage expressed in terms of sumatriptan.

Following failure to respond to first dose, reconsider diagnosis of migraine prior to administration of a second dose.

Adults

Vascular Headaches

Migraine

25, 50, or 100 mg as a single dose. Individualize dosage selection, weighing the possible benefit (greater effectiveness) and risks (increased adverse effects) of the 50- or 100-mg dose; 100-mg dose may not provide substantially greater effect than 50-mg dose.

If headache recurs or partial response occurs after initial dose, additional oral doses may be administered at intervals of ≥2 hours, up to a maximum oral dosage of 200 mg daily.

If headache recurs after an initial sub-Q dose, additional oral doses may be administered at intervals ≥2 hours, up to a maximum oral dosage of 100 mg daily.

Sumatriptan 85 mg (with naproxen sodium 500 mg) as a single dose.

Efficacy of >1 dose not established. If a second dose is administered, allow ≥2 hours to elapse between the first and second doses.

5, 10, or 20 mg as a single dose; individualize dosage selection, weighing the possible benefit (greater effectiveness) and risks (increased adverse effects) of the 20-mg dose. Doses >20 mg provide no additional benefit.

To achieve a 10-mg dose, administer a single 5-mg dose into each nostril.

If headache recurs, dose may be repeated once after 2 hours, up to a maximum dosage of 40 mg daily.

≤6 mg as a single dose. If dose-limiting adverse effects occur with 6-mg dose, lower doses (e.g., 1–5 mg) may be given.

If headache recurs, a 6-mg sub-Q dose may be repeated once after ≥1 hour or additional oral doses may be administered at intervals ≥2 hours, up to a maximum oral dosage of 100 mg daily.

If patient does not respond to first 6-mg dose, additional doses are unlikely to provide benefit.

Cluster Headache

≤6 mg as a single dose. Manufacturers state that efficacy of doses <6 mg not established; however, some patients may derive benefit from such lower doses (e.g., 3 mg).

If headache recurs, 6-mg dose may be repeated once after ≥1 hour, up to a maximum dosage of 12 mg in any 24-hour period.

If patient does not respond to first 6-mg dose, additional doses are unlikely to provide benefit.

Prescribing Limits

Adults

Vascular Headaches

Migraine

Maximum 200 mg daily; do not exceed 100 mg daily if following an initial sub-Q dose.

Safety of treating an average of >4 headaches per 30-day period has not been established.

Maximum 2 doses (total sumatriptan dosage of 170 mg) in any 24-hour period.

Safety of treating an average of >5 headaches per 30-day period has not been established.

Maximum 40 mg daily.

Safety of treating an average of >4 headaches per 30-day period has not been established.

Maximum 6 mg as a single dose; do not exceed 12 mg (i.e., two 6-mg doses given ≥1 hour apart) in any 24-hour period.

Cluster Headache

Maximum 6 mg as a single dose; do not exceed 12 mg (i.e., two 6-mg doses given ≥1 hour apart) in any 24-hour period.

Special Populations

Hepatic Impairment

Contraindicated in patients with severe hepatic impairment.

Unpredictable increases in bioavailability following oral administration in patients with hepatic impairment. If oral therapy is deemed advisable in these patients, do not exceed 50 mg as a single dose. Avoid use of fixed-combination tablets containing sumatriptan 85 mg and naproxen sodium 500 mg, since sumatriptan dosage cannot be appropriately adjusted.

Geriatric Patients

Select dosage with caution, usually starting at the low end of the dosage range.

Metabolized principally by MAO-A isoenzyme in vitro.

Protein-bound Drugs

Effect on protein binding of other drugs has not been evaluated, but expected to be minor due to low-level protein binding of sumatriptan.

Specific Drugs