THERAPEUTICS

Brands

• Sumatriptan: Imitrex, Imitrex Statdose, Sumavel DosePro, Imigran, Zecuity, Alsuma

• Sumatriptan/naproxen: Treximet

Generic?

• Yes (depending on formulation)

Class

• Triptan

Commonly Prescribed for

(FDA approved in bold)

• Acute treatment of migraine in adults

• Cluster headache (injection only)

• Acute treatment of migraine in adolescents

How the Drug Works

• Selective 5-HT1B/1D/1F receptor agonist. In addition to vasoconstriction of meningeal vessels, its antinociceptive effect is likely due to blocking the transmission of pain signals at trigeminal nerve terminals (preventing the release of inflammatory neuropeptides) and synapses of secondorder neurons in trigeminal nucleus caudalis

• Naproxen is a NSAID (cyclo-oxygenase inhibitor), which inhibits synthesis of prostaglandins, a mediator of inflammation

How Long Until It Works

• Oral or nasal spray: 1 hour or less. SC: within 10–30 minutes

If It Works

• Continue to take as needed. Patients taking acute treatment more than 2 days/week are at risk for medication-overuse headache, especially if they have migraine

If It Doesn't Work

• Treat early in the attack – triptans are less likely to work after the headache becomes moderate or severe, regardless of cutaneous allodynia, which is a marker of central sensitization

• Address life style issues (e.g., stress, sleep hygiene), medication use issues (e.g., compliance, overuse), and other underlying medical conditions

• Change to higher dosage, another triptan, another administration route, or combination of other medications. Add preventive medication when needed

• For patients with partial response or reoccurrence, other rescue medications include NSAIDs (e.g., ketorolac, naproxen), antiemetic (e.g., prochlorperazine, metoclopramide), neuroleptics (e.g., haloperidol, chlorpromazine), ergots, antihistamine, or corticosteroid

Best Augmenting Combos for Partial Response or Treatment-Resistance

• NSAIDs or neuroleptics are often used to augment response

• Use sumatriptan/naproxen combination

Tests

• None required

ADVERSE EFFECTS (AEs)

How the Drug Causes AEs

• Direct effect on systemic serotonin receptors (e.g., 5-HT1B agonism on vasoconstriction)