Dosing & Uses
Dosage Forms & Strengths
intranasal spray
- 5mg/actuation (Imitrex Intranasal)
- 10mg/actuation (Tosymra)
- 20mg/actuation (Imitrex Intranasal)
intranasal powder (Onzetra Xsail)
- 11mg/capsule in disposable nosepiece
Migraine Headache
Indicated for acute treatment of migraine headache with or without aura
Intranasal spray
- Individualized dose of 5 mg, 10 mg, or 20 mg intranasally once
- Administer 5 mg, 10 mg, or 20 mg dose into 1 nostril
- If headache returns, may repeat dose once after 2 hr; not to exceed 40 mg/day
Intranasal powder
- 22 mg (2 nosepieces) administered using the Xsail breath-powered delivery device (see Administration)
- A second 22-mg dose may be administered if the migraine has not resolved by 2 hr after taking the first dose, or returns after a transient improvement
- Not to exceed 2 doses in 24 hr (ie, 44 mg/4 nosepieces) or 1 dose of Onzetra Xsail and 1 dose of another sumatriptan product, separated by at least 2 hr
Dosing Considerations
Safety not established for treating >4 headaches/30 days
<18 years: Safety and efficacy not established
Interactions
Interaction Checker
No Results
Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor
Contraindicated (14)
- almotriptan
almotriptan, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.
- bromocriptine
bromocriptine, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.
- cabergoline
cabergoline, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.
- dihydroergotamine
dihydroergotamine, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.
- dihydroergotamine intranasal
dihydroergotamine intranasal, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.
- eletriptan
eletriptan, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.
- ergoloid mesylates
ergoloid mesylates, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.
- ergotamine
ergotamine, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.
- frovatriptan
frovatriptan, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.
- methylergonovine
methylergonovine, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.
- naratriptan
naratriptan, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.
- procarbazine
sumatriptan intranasal and procarbazine both increase serotonin levels. Contraindicated. Combination is contraindicated within 2 weeks of MAOI use.
procarbazine increases levels of sumatriptan intranasal by serotonin levels. Contraindicated. If procarbazine is required, naratriptan, eletriptan or frovatriptan may be a suitable 5-HT1D agonist to employ. Monitor for the development of serotonin toxicity/serotonin syndrome during such therapy. - rizatriptan
rizatriptan, sumatriptan intranasal. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.
- zolmitriptan
sumatriptan intranasal, zolmitriptan. Either increases toxicity of the other by pharmacodynamic synergism. Contraindicated. Additive vasospasm. Sep. by 24h.
Serious - Use Alternative (18)
- citalopram
citalopram, sumatriptan intranasal. Mechanism: unknown. Avoid or Use Alternate Drug. Combination may increase risk of serotonin syndrome. If concomitant treatment with citalopram and a triptan is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases.
- cyclobenzaprine
sumatriptan intranasal and cyclobenzaprine both increase serotonin levels. Avoid or Use Alternate Drug.
- desvenlafaxine
sumatriptan intranasal and desvenlafaxine both increase serotonin levels. Avoid or Use Alternate Drug.
- dolasetron
dolasetron, sumatriptan intranasal. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.
- granisetron
granisetron, sumatriptan intranasal. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.
- isocarboxazid
sumatriptan intranasal and isocarboxazid both increase serotonin levels. Avoid or Use Alternate Drug.
isocarboxazid increases levels of sumatriptan intranasal by decreasing metabolism. Contraindicated. - linezolid
sumatriptan intranasal and linezolid both increase serotonin levels. Avoid or Use Alternate Drug. Linezolid may increase serotonin as a result of MAO-A inhibition. If linezolid must be administered, discontinue serotonergic drug immediately and monitor for CNS toxicity. Serotonergic therapy may be resumed 24 hours after last linezolid dose or after 2 weeks of monitoring, whichever comes first.
linezolid increases levels of sumatriptan intranasal by decreasing metabolism. Contraindicated. - lorcaserin
sumatriptan intranasal and lorcaserin both increase serotonin levels. Avoid or Use Alternate Drug.
- methylene blue
sumatriptan intranasal and methylene blue both increase serotonin levels. Avoid or Use Alternate Drug. Methylene blue may increase serotonin as a result of MAO-A inhibition. If methylene blue must be administered, discontinue serotonergic drug immediately and monitor for CNS toxicity. Serotonergic therapy may be resumed 24 hours after last methylene blue dose or after 2 weeks of monitoring, whichever comes first.
- netupitant/palonosetron
netupitant/palonosetron, sumatriptan intranasal. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.
- ondansetron
ondansetron, sumatriptan intranasal. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.
- ozanimod
ozanimod increases toxicity of sumatriptan intranasal by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Avoid or Use Alternate Drug. Because the active metabolite of ozanimod inhibits MAO-B in vitro, there is a potential for serious adverse reactions, including hypertensive crisis. Therefore, coadministration of ozanimod with drugs that can increase norepinephrine or serotonin is not recommended. Monitor for hypertension with concomitant use.
- palonosetron
palonosetron, sumatriptan intranasal. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug.
- phenelzine
sumatriptan intranasal and phenelzine both increase serotonin levels. Avoid or Use Alternate Drug.
phenelzine increases levels of sumatriptan intranasal by decreasing metabolism. Contraindicated. - tedizolid
tedizolid, sumatriptan intranasal. Either increases effects of the other by Mechanism: pharmacodynamic synergism. Avoid or Use Alternate Drug. both increase serotonin levels; increased risk of serotonin syndrome.
- tranylcypromine
sumatriptan intranasal and tranylcypromine both increase serotonin levels. Avoid or Use Alternate Drug. Concomitant use or use within 2 wks following the discontinuation of tranylcypromine is contraindicated.
tranylcypromine increases levels of sumatriptan intranasal by decreasing metabolism. Contraindicated. - vilazodone
sumatriptan intranasal, vilazodone. Either increases toxicity of the other by serotonin levels. Avoid or Use Alternate Drug. Concomitant therapy should be discontinued immediately if signs or symptoms of serotonin syndrome emerge and supportive symptomatic treatment should be initiated. .
- vortioxetine
sumatriptan intranasal, vortioxetine. Either increases effects of the other by serotonin levels. Avoid or Use Alternate Drug.
Monitor Closely (84)
- 5-HTP
sumatriptan intranasal and 5-HTP both increase serotonin levels. Use Caution/Monitor.
- almotriptan
almotriptan and sumatriptan intranasal both increase serotonin levels. Use Caution/Monitor.
- amitriptyline
sumatriptan intranasal and amitriptyline both increase serotonin levels. Modify Therapy/Monitor Closely.
- amoxapine
sumatriptan intranasal and amoxapine both increase serotonin levels. Modify Therapy/Monitor Closely.
- aripiprazole
sumatriptan intranasal, aripiprazole. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- asenapine
sumatriptan intranasal, asenapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- benzhydrocodone/acetaminophen
benzhydrocodone/acetaminophen, sumatriptan intranasal. Either increases effects of the other by serotonin levels. Use Caution/Monitor. Coadministration of drugs that affect the serotonergic neurotransmitter system may result in serotonin syndrome. If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation and dose adjustment.
- buspirone
sumatriptan intranasal and buspirone both increase serotonin levels. Modify Therapy/Monitor Closely.
- cariprazine
sumatriptan intranasal, cariprazine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- clomipramine
sumatriptan intranasal and clomipramine both increase serotonin levels. Modify Therapy/Monitor Closely.
- clozapine
sumatriptan intranasal, clozapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- cocaine topical
sumatriptan intranasal and cocaine topical both increase serotonin levels. Modify Therapy/Monitor Closely.
- cyproheptadine
cyproheptadine decreases effects of sumatriptan intranasal by pharmacodynamic antagonism. Use Caution/Monitor. Cyproheptadine may diminish the serotonergic effect of serotonin agonists.
- desipramine
sumatriptan intranasal and desipramine both increase serotonin levels. Modify Therapy/Monitor Closely.
- dexfenfluramine
sumatriptan intranasal and dexfenfluramine both increase serotonin levels. Use Caution/Monitor.
- dextroamphetamine
sumatriptan intranasal and dextroamphetamine both increase serotonin levels. Use Caution/Monitor.
- dextromethorphan
sumatriptan intranasal and dextromethorphan both increase serotonin levels. Modify Therapy/Monitor Closely.
- dihydroergotamine
sumatriptan intranasal and dihydroergotamine both increase serotonin levels. Use Caution/Monitor.
- dihydroergotamine intranasal
sumatriptan intranasal and dihydroergotamine intranasal both increase serotonin levels. Use Caution/Monitor.
- dosulepin
sumatriptan intranasal and dosulepin both increase serotonin levels. Modify Therapy/Monitor Closely.
- doxepin
sumatriptan intranasal and doxepin both increase serotonin levels. Modify Therapy/Monitor Closely.
- droxidopa
sumatriptan intranasal and droxidopa both increase sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. May increase risk for supine hypertension
- duloxetine
sumatriptan intranasal and duloxetine both increase serotonin levels. Modify Therapy/Monitor Closely.
- eletriptan
eletriptan and sumatriptan intranasal both increase serotonin levels. Use Caution/Monitor.
- ergotamine
sumatriptan intranasal and ergotamine both increase serotonin levels. Use Caution/Monitor.
- escitalopram
sumatriptan intranasal and escitalopram both increase serotonin levels. Modify Therapy/Monitor Closely.
- fenfluramine
sumatriptan intranasal and fenfluramine both increase serotonin levels. Use Caution/Monitor.
fenfluramine, sumatriptan intranasal. Either increases effects of the other by serotonin levels. Use Caution/Monitor. Coadministration with drugs that increase serotoninergic effects may increase the risk of serotonin syndrome. - fluoxetine
sumatriptan intranasal and fluoxetine both increase serotonin levels. Modify Therapy/Monitor Closely.
- fluphenazine
sumatriptan intranasal, fluphenazine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- fluvoxamine
fluvoxamine and sumatriptan intranasal both increase serotonin levels. Modify Therapy/Monitor Closely.
- frovatriptan
frovatriptan and sumatriptan intranasal both increase serotonin levels. Use Caution/Monitor.
- haloperidol
sumatriptan intranasal, haloperidol. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- hydrocodone
hydrocodone, sumatriptan intranasal. Either increases effects of the other by serotonin levels. Use Caution/Monitor. Coadministration of drugs that affect the serotonergic neurotransmitter system may result in serotonin syndrome. If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation and dose adjustment.
- iloperidone
sumatriptan intranasal, iloperidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- imipramine
sumatriptan intranasal and imipramine both increase serotonin levels. Modify Therapy/Monitor Closely.
- isoniazid
sumatriptan intranasal and isoniazid both increase serotonin levels. Use Caution/Monitor.
- L-tryptophan
sumatriptan intranasal and L-tryptophan both increase serotonin levels. Use Caution/Monitor.
- levodopa
sumatriptan intranasal and levodopa both increase serotonin levels. Use Caution/Monitor.
- levomilnacipran
sumatriptan intranasal and levomilnacipran both increase serotonin levels. Modify Therapy/Monitor Closely.
- lisdexamfetamine
sumatriptan intranasal and lisdexamfetamine both increase serotonin levels. Use Caution/Monitor.
- lithium
sumatriptan intranasal and lithium both increase serotonin levels. Use Caution/Monitor.
- lofepramine
sumatriptan intranasal and lofepramine both increase serotonin levels. Modify Therapy/Monitor Closely.
- loxapine
sumatriptan intranasal, loxapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- loxapine inhaled
sumatriptan intranasal, loxapine inhaled. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- lsd
sumatriptan intranasal and lsd both increase serotonin levels. Use Caution/Monitor.
- lurasidone
sumatriptan intranasal, lurasidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- maprotiline
sumatriptan intranasal and maprotiline both increase serotonin levels. Modify Therapy/Monitor Closely.
- meperidine
sumatriptan intranasal and meperidine both increase serotonin levels. Modify Therapy/Monitor Closely.
- milnacipran
sumatriptan intranasal and milnacipran both increase serotonin levels. Modify Therapy/Monitor Closely.
- mirtazapine
sumatriptan intranasal and mirtazapine both increase serotonin levels. Use Caution/Monitor.
- molindone
sumatriptan intranasal, molindone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- morphine
sumatriptan intranasal and morphine both increase serotonin levels. Use Caution/Monitor.
- naratriptan
naratriptan and sumatriptan intranasal both increase serotonin levels. Use Caution/Monitor.
- nefazodone
sumatriptan intranasal and nefazodone both increase serotonin levels. Modify Therapy/Monitor Closely.
- nortriptyline
sumatriptan intranasal and nortriptyline both increase serotonin levels. Modify Therapy/Monitor Closely.
- olanzapine
sumatriptan intranasal, olanzapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- oliceridine
sumatriptan intranasal, oliceridine. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely.
- paliperidone
sumatriptan intranasal, paliperidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- paroxetine
sumatriptan intranasal and paroxetine both increase serotonin levels. Modify Therapy/Monitor Closely.
- pentazocine
sumatriptan intranasal and pentazocine both increase serotonin levels. Use Caution/Monitor.
- perphenazine
sumatriptan intranasal, perphenazine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- pimavanserin
sumatriptan intranasal, pimavanserin. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- pimozide
sumatriptan intranasal, pimozide. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- protriptyline
sumatriptan intranasal and protriptyline both increase serotonin levels. Modify Therapy/Monitor Closely.
- quetiapine
sumatriptan intranasal, quetiapine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- rasagiline
sumatriptan intranasal and rasagiline both increase serotonin levels. Modify Therapy/Monitor Closely.
- remifentanil
remifentanil increases toxicity of sumatriptan intranasal by serotonin levels. Modify Therapy/Monitor Closely. Increases risk of serotonin syndrome.
- risperidone
sumatriptan intranasal, risperidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- rizatriptan
rizatriptan and sumatriptan intranasal both increase serotonin levels. Use Caution/Monitor.
- SAMe
sumatriptan intranasal and SAMe both increase serotonin levels. Use Caution/Monitor.
- selegiline
sumatriptan intranasal and selegiline both increase serotonin levels. Modify Therapy/Monitor Closely.
- selegiline transdermal
sumatriptan intranasal and selegiline transdermal both increase serotonin levels. Modify Therapy/Monitor Closely.
- sertraline
sumatriptan intranasal and sertraline both increase serotonin levels. Modify Therapy/Monitor Closely.
- St John's Wort
sumatriptan intranasal and St John's Wort both increase serotonin levels. Modify Therapy/Monitor Closely.
- sufentanil SL
sufentanil SL, sumatriptan intranasal. Either increases effects of the other by serotonin levels. Use Caution/Monitor. Coadministration of drugs that affect the serotonergic neurotransmitter system may result in serotonin syndrome. If concomitant use is warranted, carefully observe the patient, particularly during treatment initiation and dose adjustment.
- tapentadol
sumatriptan intranasal and tapentadol both increase serotonin levels. Modify Therapy/Monitor Closely.
- thiothixene
sumatriptan intranasal, thiothixene. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- tramadol
sumatriptan intranasal and tramadol both increase serotonin levels. Use Caution/Monitor.
- trazodone
sumatriptan intranasal and trazodone both increase serotonin levels. Modify Therapy/Monitor Closely.
- trifluoperazine
sumatriptan intranasal, trifluoperazine. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- trimipramine
sumatriptan intranasal and trimipramine both increase serotonin levels. Modify Therapy/Monitor Closely.
- venlafaxine
sumatriptan intranasal and venlafaxine both increase serotonin levels. Modify Therapy/Monitor Closely.
- ziprasidone
sumatriptan intranasal, ziprasidone. unspecified interaction mechanism. Use Caution/Monitor. Serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotics may enhance serotonergic effect of serotonin modulators, which may result in serotonin syndrome. Monitor for evidence of serotonin toxicity (eg, mental status changes, autonomic instability, and neuromuscular hyperactivity) or neuroleptic malignant syndrome (eg, hyperthermia, muscle rigidity, autonomic dysfunction).
- zolmitriptan
sumatriptan intranasal and zolmitriptan both increase serotonin levels. Use Caution/Monitor.
Minor (9)
- duloxetine
duloxetine, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.
- escitalopram
escitalopram, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.
- fluoxetine
fluoxetine, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.
- milnacipran
milnacipran, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.
- nefazodone
nefazodone, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.
- paroxetine
paroxetine, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.
- sertraline
sertraline, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.
- trazodone
trazodone, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.
- venlafaxine
venlafaxine, sumatriptan intranasal. Mechanism: unknown. Minor/Significance Unknown. Risk of weakness, dyspnea, chest pain.
Adverse Effects
>10%
Bad/unusual taste (13.5-24.5%)
Gastrointestinal: nausea/vomiting (11-13.5%)
1-10%
Disorder/discomfort of nasal cavity/sinuses (2.5-3.8%)
Throat discomfort (0.8-2.4%)
Dizziness/vertigo (1-1.7%)
Burning sensation (0.4-1.4%)
Frequency Not Defined
Atypical Sensations: Tingling, numbness, pressure sensation, cold sensation, feeling of tightness
Cardiovascular: Flushing, hypertension, palpations, tachycardia, arrhythmia, edema
Chest tightness/discomfort, chest pressure/heaviness
Disturbance of hearing, ear infections
Eye irritation and visual disturbances
Gastrointestinal: Abdominal discomfort, diarrhea, dysphagia, GERD, dry mouth, thirst
Musculoskeletal: Neck pain/stiffness, backache, weakness, joint symptoms, arthritis, myalgia, muscle cramps
Neurological: Drowsiness/sedation, anxiety, sleep disturbances, tremors, syncope, chills, depression, agitation, confusion
Respiratory: Dyspnea, lower respiratory infection
Skin: Rash/skin eruption, pruritus, erythema
Urogenital: Dysuria, dysmenorrhea
Postmarketing Reports
Blood: Hemolytic anemia, pancytopenia, thrombocytopenia
Cardiovascular: Atrial fibrillation, cardiomyopathy, colonic ischemia, Prinzmetal variant angina, pulmonary embolism, shock, thrombophlebitis
Ear, nose, throat: Deafness
Eye: Ischemic optic neuropathy, retinal artery occlusion, retinal vein thrombosis, loss of vision
Gastrointestinal: Ischemic colitis, dry mouth
Hepatic: Elevated LFTs
Neurological: CNS vasculitis, cerebrovascular accident, dysphasia, serotonin syndrome, subarachnoid hemorrhage
Psychiatric: Panic disorder
Respiratory: bronchospasm in patients with or without a history of asthma
Skin: exacerbation of sunburn, hypersensitivity reactions (erythema, pruritus, rash), photosensitivity
Urogenital: acute renal failure
Nonspecific: Angioneurotic edema, cyanosis, death, temporal arteritis
Warnings
Contraindications
Ischemic coronary artery disease (CAD) (eg, angina pectoris, history of myocardial infarction, or silent ischemia) or coronary artery vasospasm, including Prinzmetal’s angina or in patients with other significant underlying cardiovascular diseases
Wolff-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders
History of stroke, transient ischemic attack (TIA), or history of hemiplegic or basilar migraine
Peripheral vascular disease
Ischemic bowel
Uncontrolled hypertension
Recent use (eg, within 24 hours) of ergotamine-containing medication, ergot-type medication (such as dihydroergotamine or methysergide), or another 5-hydroxytryptamine1 (5-HT1) agonist
Concurrent administration of an MAO-A inhibitor or recent use (within 2 weeks) of an MAO-A inhibitor
Hypersensitivity to sumatriptan (angioedema and anaphylaxis seen)
Severe hepatic impairment
Cautions
Local irritation of nose and throat reported
Sensations of tightness, pain, pressure, and heaviness in chest, throat, neck, and jaw commonly occur after treatment with 5-HT1 agonists including other products containing sumatriptan and are usually non-cardiac in origin; however, perform a cardiac evaluation if these patients are at high cardiac risk; therapy is contraindicated in patients with known CAD and those with Prinzmetal’s variant angina
Significant elevation in blood pressure, including hypertensive crisis with acute impairment of organ systems, reported on rare occasions in patients treated with 5-HT1 agonists, including patients without a history of hypertension; monitor blood pressure in patients treated with this drug; therapy is contraindicated in patients with uncontrolled hypertension
Hypersensitivity reactions, including angioedema and anaphylaxis, have occurred in patients receiving sumatriptan; such reactions can be life-threatening or fatal; in general, anaphylactic reactions to drugs are more likely to occur in individuals with a history of sensitivity to multiple allergens; therapy is contraindicated in patients with history of hypersensitivity reaction to this drug
Seizures reported following administration of therapy; some have occurred in patients with either a history of seizures or concurrent conditions predisposing to seizures; there are also reports in patients where no such predisposing factors are apparent; this drug should be used with caution in patients with a history of epilepsy or conditions associated with a lowered seizure threshold
Medication Overuse Headache
- Overuse of acute migraine drugs (eg, ergotamine, triptans, opioids, nonsteroidal anti-inflammatory drugs or combinations of these drugs for 10 or more days per month) may lead to exacerbation of headache (medication overuse headache)
- Medication overuse headache may present as migraine-like daily headaches or as a marked increase in frequency of migraine attacks
- Detoxification of patients, including withdrawal of overused drugs, and treatment of withdrawal symptoms (which often includes a transient worsening of headache) may be necessary
Arrhythmias
- Life-threatening disturbances of cardiac rhythm, including ventricular tachycardia and ventricular fibrillation leading to death, reported within a few hours following administration of therapy
- Discontinue therapy if these disturbances occur; therapy is contraindicated in patients with Wolff-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders
Myocardial Ischemia, myocardial Infarction, and Prinzmetal’s angina
- There are rare reports of serious cardiac adverse reactions, including acute myocardial infarction, occurring within a few hours following administration of therapy; some occurred in patients without known CAD
- 5-HT1 agonists may cause coronary artery vasospasm (Prinzmetal’s angina), even in patients without a history of CAD
- Perform a cardiovascular evaluation in triptan-naïve patients who have multiple cardiovascular risk factors (e.g., increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD) prior to receiving therapy
- If there is evidence of CAD or coronary artery vasospasm, therapy is contraindicated; for patients with multiple cardiovascular risk factors who have a negative cardiovascular evaluation, consider administering the first dose in a medically supervised setting and performing an electrocardiogram (ECG) immediately following administration
- For such patients, consider periodic cardiovascular evaluation in intermittent long-term users of the drug
Cardiovascular events
- Cerebral hemorrhage, subarachnoid hemorrhage, stroke, and other cerebrovascular events have occurred in patients treated with 5-HT1 agonists including other products containing sumatriptan, and some have resulted in fatalities
- In some cases, it appears possible that the cerebrovascular events were primary, the 5-HT1 agonist having been administered in the incorrect belief that the symptoms experienced were a consequence of migraine when they were not
- Patients with migraine may be at increased risk of certain cerebrovascular events (eg, stroke, hemorrhage, TIA); therapy is contraindicated in patients with a history of stroke or TIA; discontinue therapy if a cerebrovascular event occurs
- Before treating headaches in patients not previously diagnosed as migraineurs, and in migraineurs who present with atypical symptoms, exclude other potentially serious neurological conditions
Other vasospasm reactions
- 5-HT1 agonists may cause non-coronary vasospastic reactions, such as peripheral vascular ischemia, gastrointestinal vascular ischemia and infarction (presenting with abdominal pain and bloody diarrhea), splenic infarction, and Raynaud’s syndrome
- In patients who experience symptoms or signs suggestive of a non-coronary vasospastic reaction following use of any 5-HT1 agonist, rule out a vasospastic reaction before using this drug
- Transient and permanent blindness and significant partial vision loss have been reported with the use of 5-HT1 agonists including this drug
- Since visual disorders may be part of a migraine attack, a causal relationship between these events and the use of 5-HT1 agonists have not been clearly established
Serotonin Syndrome
- Serotonin syndrome may occur with triptans, including this drug, particularly during co-administration with selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and MAO inhibitors
- Serotonin syndrome symptoms may include mental status changes (eg, agitation, hallucinations, coma), autonomic instability (eg, tachycardia, labile blood pressure, hyperthermia), neuromuscular abnormalities (eg, hyperreflexia, incoordination), and/or gastrointestinal symptoms (eg, nausea, vomiting, diarrhea)
- The onset of symptoms usually occurs within minutes to hours of receiving a new or a greater dose of a serotonergic medication; discontinue therapy if serotonin syndrome is suspected
Pregnancy & Lactation
Pregnancy
Data from prospective pregnancy exposure registry and epidemiological studies of pregnant women have not detected an increased frequency of birth defects or a consistent pattern of birth defects among women exposed to sumatriptan compared with the general population
Several studies have suggested that women with migraine may be at increased risk of preeclampsia and gestational hypertension during pregnancy
Animal data
- In developmental toxicity studies in rats and rabbits, oral administration to pregnant animals was associated with embryolethality, fetal abnormalities, and pup mortality; when administered by intravenous route to pregnant rabbits, sumatriptan was embryo lethal
Lactation
This drug is excreted in human milk following subcutaneous administration; there is no information regarding concentrations of this drug in milk from lactating women following administration of therapy
There are no data on effects of sumatriptan on breastfed infant or effects of this drug on milk production
The developmental and health benefits of breastfeeding should be considered along with mother's clinical need for this drug and any potential adverse effects on breastfed infants from sumatriptan or from underlying maternal condition
Infant exposure to sumatriptan can be minimized by avoiding breastfeeding for 12 hours after treatment with this drug
Pregnancy Categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available.Pharmacology
Mechanism of Action
Selective 5-HT1 receptor agonist in cranial arteries; elicits vasoconstrictive and anti-inflammatory effects; associated with antidromic neuronal transmission and relief of migraine headache
Absorption
Bioavailability: 80-100%
Onset: 30 min
Peak Plasma Concentration: 5-16 ng/mL (dose dependent)
Distribution
Protein Bound: 14-21%
Metabolism
Metabolized by MAO-A
Metabolites: indole acetic acid analogue of sumatriptan
Elimination
Half-life: 2 hr
Total body clearance: 1,200 mL/min
Excretion: urine (3% unchanged, 42% as major metabolite)
Administration
Intranasal Administration
Imitrex Intranasal Spray
Imitrex Intranasal
- Administer 5 mg or 20 mg metered-spray dose into 1 nostril
- 10 mg dose achieved by administering 5 mg in each nostril
Tosymra
- Administer 10 mg metered-spray dose into 1 nostril
- 20 mg dose achieved by administering 10 mg in each nostril
Onzetra Xsail
- Remove the clear device cap from the reusable delivery device, then remove a disposable nosepiece from its foil pouch and click the nosepiece into the device body
- Fully press and promptly release the white piercing button on the device body to pierce the capsule inside the nosepiece; the white piercing button should only be pressed once and released prior to administration to each nostril
- Insert the nosepiece is then inserted into the nostril so that it makes a tight seal; keeping the nosepiece in the nose, rotate the device to place the mouthpiece into the mouth
- The patient blows forcefully through the mouthpiece to deliver the sumatriptan powder into the nasal cavity
- Vibration (eg, a rattling noise) may occur, and indicates that the patient is blowing forcefully, as directed
- Once the medication in the first nosepiece has been administered, remove and discard the nosepiece
- The same process must then be repeated using a second 11 mg nosepiece into the other nostril to administer the remainder of the total recommended 22 mg dose
Storage
Imitrex Intranasal
- Store between 36-86°F (2-30°C)
- Protect from light
Onzetra Xsail
- Store at room temperature between 20-25°C (68-77°F), with excursions permitted between 15-30°C (59-86°F)
- Do not store in the refrigerator or freezer
- Use nosepiece immediately after removing from foil pouch
Images
Formulary
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