SUMATRIPTAN
Clinical Criteria Summary
Indications for Treatment
- Sumatriptan oral, nasal, and subcutaneous injection: FDA approved indication for acute treatment of migraine with or without aura.
- Subcutaneous injection only: FDA approved indication for acute treatment of cluster headache.
Cluster Headache
- Clinical Presentation
- Rapid escalation to maximum intensity with typical durations of less than one hour; non-oral treatment recommended in most cases due to faster onset of action.
- Pharmacologic Options
- Sumatriptan nasal spray 20 mg once in the nostril contralateral to the side of headache. May repeat a single 20 mg dose after > 2 hours if needed. Maximum dose: 40 mg per 24 hours.
- Zolmitriptan nasal spray 5 to 10 mg once in the nostril contralateral to the side of headache. May repeat a single 5 mg dose after > 2 hours if needed. Maximum dose: 10 mg per 24 hours. (Note: 10 mg as a single dose is off-label for cluster headache; only available as 2.5 mg or 5 mg dose).
- Intranasal triptans do not have an FDA-approved indication for cluster headache but evidence supports their use and they are commonly used by clinicians.
- Non-Pharmacologic Options
- High-flow normobaric oxygen: 12 to 15 L/min for 20 minutes via non-rebreather mask.
- Non-invasive vagus nerve stimulator (gammaCoreTM): Two two-minute stimulations. Both stimulations may be performed on the same side of the neck or the patient can switch sides for the second stimulation. Requires training per product information.
Migraine Headache
- Clinical Presentation
- Often associated with severe nausea with or without vomiting and/or rapid escalation to maximum intensity; non-oral, faster-onset dosage forms more desirable.
- Pharmacologic Options
- Rizatriptan ODT: 5 to 10 mg. May repeat a single dose after > 2 hours if needed. Maximum dose: 30 mg per 24 hours.
- Zolmitriptan ODT: 1.25 to 5 mg. May repeat a single dose after > 2 hours if needed. Maximum dose: 10 mg per 24 hours.
- Rimegepant ODT: 75 mg. Maximum dose: 75 mg per 24 hours.
- Sumatriptan nasal spray: 5 mg to 20 mg in one nostril. May repeat a single dose after > 2 hours if needed. Maximum dose: 40 mg per 24 hours.
- Zolmitriptan nasal spray: 2.5 to 5 mg in one nostril. May repeat a single dose after > 2 hours if needed. Maximum dose: 10 mg per 24 hours.
- Dihydroergotamine (DHE) nasal spray (MIGRANAL): 0.5 mg per spray; 1 spray into each nostril, repeat after 15 minutes. Maximum: 4 sprays (2 doses) per 24-hours. Similar contraindications as triptans in vascular disease. Cannot be given within 24 hours of a triptan or vice versa.
- Dihydroergotamine HFA nasal spray (TRUDHESA): 0.725 mg per spray; 1 spray into each nostril, may repeat after > 1 hour if needed. Maximum: 4 sprays (2 doses) per 24-hours.
- Zavegepant nasal spray: 10 mg per spray; 1 spray in one nostril as a single dose. Maximum: 10 mg per 24-hours.
- Non-Pharmacologic Options
- Neuromodulation devices: Multiple options including non-invasive vagus nerve stimulator (gammaCoreTM) and external trigeminal nerve stimulator (CefalyTM). Requires training per product information.
- Administration & Safety Considerations
- ODTs can be considered for patients with severe nausea without vomiting. Avoid in patients who experience vomiting as they require gastrointestinal absorption (not buccally or sublingually absorbed).
- Adding an antiemetic may benefit patients experiencing severe nausea and vomiting with migraines.
General Prescribing Considerations
- Alternatives should be evaluated case-by-case with the patient’s headache provider based on clinical context.
- Drug interactions may exist for some pharmacologic options that are different from sumatriptan.
- Refer to PBM INTRAnet or VA Formulary Advisor for current formulary status, additional formulary information, and VA Criteria for Use.