Use in Adults
Triptans Nasal Sprays and Powder
THIS GUIDE PROVIDES A PARTIAL LISTING OF PRESCRIBING INFORMATION FOR THIS MEDICATION. FOR A FULL LISTING OF PRESCRIBING INFORMATION PLEASE REFER TO THE PACKAGE INSERT. CLICK ON THE BRAND NAME® TO VIEW THE LINK TO THE PACKAGE INSERT.
Sumatriptan Intranasal (Imitrex®) Click here to expand
Brands: Available Dosages:
- 5 mg and 20 mg nasal sprays
- 20 mg is most common initial dosage
- If patient has medication intolerance might consider a 5 mg dose
- One single spray in one nostril provides either a 20 mg dosage for the 20 mg nasal spray or a 5 mg dosage for the 5 mg nasal spray
- 20 mg for acute migraine attack, may repeat in 2 hours if not pain free or adequate pain relief
- No more than 2 dosages per day
- 40 mg
- Tightness in throat and chest, dizziness, or sedation/fatigue, tingling in the hands and feet
- May be used as a primary therapy for migraine.
- May be used as rescue therapy in a person with persistent headache 2-24 hours after use of sumatriptan tablet
- May also be a good alternative to patients who are “needle phobic”, but still need a fast onset of action.
- Sumatriptan nasal sprays are considered to have a faster onset of action than sumatriptan tablets, but a slower onset of action than the injectables.
- Triptans have a higher incidence of side effects than many NSAIDS and gepants. Side effects include paresthesias, neck tightness, chest pain/discomfort, dizziness and somnolence, which have been termed “triptan side effects”. Patients need to be warned of these side effects prior to their initial use. If not, some patients may delay use of triptans because of fear of these side effects.
- Sumatriptan should not be used in those with known cardiovascular disease (CAD, stroke, Prinzmetal’s angina, peripheral vascular disease, mesenteric ischemia), hemiplegic migraine and basilar type migraine. It should be used with caution in those with two more cardiovascular risk factors. Some clinicians recommend cardiac evaluation to exclude unrecognized cardiovascular disease prior to use of sumatriptan or other triptans in patients who have two or more cardiovascular risk factors.
- Main advantages are good efficacy, a long safety record for use and multiple formulations to choose (e.g., tablets, nasal sprays, injectables).
- Main disadvantages are a higher incidence of side effects and the potential need to screen those with migraine for cardiovascular or other vascular risk prior to use of the triptans. In addition, some patients may prefer an oral route of delivery.
- Many insurance plans require that those with migraine “try and fail” 1-2 triptans prior to using other newer acute medications (e.g., gepants, ditans and some older agents such as ergots).
- Do not use in the setting of coronary artery disease, unstable angina, hx of stroke, basilar-type or hemiplegic migraine, uncontrolled hypertension, vasculitides, including ischemic bowel disease.
- Limit use to 10 or fewer days per month to prevent medication overuse headache.
- Arrhythmias associated with cardiac accessory conduction pathway disorders, including Wolff-Parkinson-White syndrome
- Concomitant administration of MAO-A inhibitors or use within 2 weeks of discontinuation of MAO-A inhibitor therapy
- Concomitant use of ergotamine-containing or ergot-type medication (e.g., dihydroergotamine, methysergide) within 24 hours
- Concomitant use with a different triptan or ergot within 24 hours
- Coronary artery vasospasm, including Prinzmetal’s angina, or other significant underlying cardiovascular disease
- History of hemiplegic or basilar-type migraine
- History of stroke or transient ischemic attack
- Hypersensitivity to sumatriptan or any of its components
- Ischemic bowel disease
- Ischemic coronary artery disease (angina pectoris, history of myocardial infarction, or documented silent ischemia)
- Peripheral vascular disease
- Severe hepatic impairment
- Uncontrolled hypertension
- Click Imitrex® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- Do not use within 24 hours of another triptan or ergotamine
- Pharmacists frequently report a drug interaction between triptans and serontonergic anti-depressants because of the risk of serotonin syndrome. However, this is felt to be a theoretical risk. Sufficient evidence to support the contention that combined use of triptans and serotonergic anti-depressants is unsafe has not been established. This is reflected in a position statement from the American Headache Society (Evans R. Headache 2010; 50: 1089-99) Therefore, headache physicians commonly co-administer antidepressants and triptans in the same patient.
- Keep head upright, or tilted only slightly forward, during administration and for 10-20 seconds after administration
- Do not lean fully forward or backward, when administering or medication will run out the nose, or down the throat
- Occlude the opposite nostril when administering
- Breath normally, or hold breath for seconds during administration; do not snort the medication or it will go in the posterior pharynx and be swallowed; this will delay absorption of medication
- May repeat dosage after 2 hours if not pain free or having adequate pain relief; limit to two doses in 24 hours
Sumatriptan Intranasal (Tosymra®) Click Here to Expand
Brands:
Tosymra® (sumatriptan) For more complete prescribing information click here for PACKAGE INSERT
Initial Dose:
Tosymra® (sumatriptan) For more complete prescribing information click here for PACKAGE INSERT
Initial Dose:
- 10 mg
- 10 mg
- One spray in one nostril (10 mg total dosage), first dose at onset of migraine,
- Up to three doses in a 24 hour period
- Wait at least 1 hour between dosages.
- 30 mg
- Tightness in throat and chest, dizziness, or sedation/fatigue, tingling in the hands and feet
- Sumatriptan nasal sprays are considered to have a faster onset of action than sumatriptan tablets, but a slower onset of action than injectable sumatriptan.
- May be a good alternative to patients that are “needle phobic”, but still need a fast onset of action.
- Main disadvantages are dysgeusia as a side effect and that some patients may prefer an oral route of delivery.
- Triptans have a higher incidence of side effects than many NSAIDS and gepants. Side effects include paresthesias, neck tightness, chest pain/discomfort, dizziness and somnolence, which have been termed “triptan side effects”. Patients need to be warned of these side effects prior to their initial use. If not, some patients may delay use of triptans because of fear of these side effects.
- Sumatriptan should not be used in those with known cardiovascular disease (CAD, stroke, transient ischemic attacks, Prinzmetal’s angina, peripheral vascular disease, mesenteric ischemia), hemiplegic migraine and basilar type migraine. It should be used with caution in those with two more cardiovascular risk factors. Some clinicians recommend cardiac evaluation to exclude unrecognized cardiovascular disease prior to use of sumatriptan or other triptans in patients who have two or more cardiovascular risk factors.
- Main advantages are good efficacy, a long safety record for use and multiple formulations from which to choose (tablets, nasal sprays, injectables).
- Main disadvantages are a higher incidence of side effects and the potential need to screen those with cardiovascular risk factors prior to use
- Many insurance plans require that those with migraine “try and fail” 1-2 triptans prior to using other newer acute medications (e.g., gepants, ditans and some older agents such as ergots).
- Do not use in the setting of coronary artery disease, unstable angina, hx of stroke, basilar-type or hemiplegic migraine, uncontrolled hypertension, vasculitides, including ischemic bowel disease.
- Limit use to 10 or fewer days per month to prevent medication overuse headache.
- Arrhythmias associated with cardiac accessory conduction pathway disorders, including Wolff-Parkinson-White syndrome
- Concomitant administration of MAO-A inhibitors or use within 2 weeks of discontinuation of MAO-A inhibitor therapy
- Concomitant use of ergotamine-containing or ergot-type medication (e.g., dihydroergotamine, methysergide) within 24 hours
- Concomitant use with a different triptan or ergot within 24 hours
- Coronary artery vasospasm, including Prinzmetal’s angina, or other significant underlying cardiovascular disease
- History of hemiplegic or basilar-type migraine
- History of stroke or transient ischemic attack
- Hypersensitivity to sumatriptan or any of its components
- Ischemic bowel disease
- Ischemic coronary artery disease (angina pectoris, history of myocardial infarction, or documented silent ischemia)
- Peripheral vascular disease
- Severe hepatic impairment
- Uncontrolled hypertension
- Click Tosymra® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- Do not use within 24 hours of another triptan or ergotamine
- Pharmacists frequently report a drug interaction between triptans and anti-depressants because of the risk of serotonin syndrome. However, this is felt to be a theoretical risk. Sufficient evidence to support the contention that combined use of triptans and serotonergic anti-depressants is unsafe has not been established. This is reflected in a position statement from the American Headache Society (Evans R. Headache 2010; 50: 1089-99) Therefore, headache physicians commonly co-administer antidepressants and triptans in the same patient.
- Keep head upright during administration and for 10-20 seconds after administration
- Do not lean forward when administering or medication will run out the nose and not be absorbed
- Occlude the opposite nostril when administering
- Breath normally during administration; do not snort the medication or it will drain into the posterior pharynx and be swallowed; this will delay absorption of medication
- May repeat dosage after 1 hour, if not pain free or having adequate pain relief, limit to three doses per day, or 30 mg doses in a 24 hour period.
Sumatriptan Nasal Powder (Onzetra®) Click Here to Expand
Brands:
- Onzetra® Xsail (sumatriptan) For more complete prescribing information click here for PACKAGE INSERT
- 22 mg sumatriptan nasal powder
- 22 mg is the initial dosage (1 spray in each nostril provides a total dosage of 22 mg of sumatriptan nasal power)
- 22 mg at onset of migraine, may repeat in 1 hour if not pain free or having adequate pain relief
- Limit to two doses. One spray in each nostril is considered one dose. Therefore, limit to a total of 4 sprays in 24 hours
- 44 mg
- Tightness in throat and chest, dizziness, or sedation/fatigue, tingling in the hands and feet
- Sumatriptan nasal sprays are considered to have a faster onset of action than sumatriptan tablets, but a slower onset of action than the injectables.
- Intranasal delivery may be a good alternative to patients who are “needle phobic”, but still need a fast onset of action.
- Triptans have a higher incidence of side effects than many NSAIDS and gepants. Side effects include paresthesias, neck tightness, chest pain/discomfort, dizziness and somnolence, which have been termed “triptan side effects”. Patients need to be warned of these side effects prior to their initial use. If not, some patients may delay use of triptans because of fear of these side effects.
- Sumatriptan should not be used in those with known cardiovascular disease (CAD, stroke, Prinzmetal’s angina, peripheral vascular disease, mesenteric ischemia), hemiplegic migraine and basilar type migraine. It should be used with caution in those with two more cardiovascular risk factors. Some clinicians recommend cardiac evaluation to exclude unrecognized cardiovascular disease prior to use of sumatriptan or other triptans in patients who have two or more cardiovascular risk factors.
- Main advantages are good efficacy, a long safety record for use and multiple formulations from which to choose (e.g., tablets, nasal sprays, injectables).
- Main disadvantages are a higher incidence of side effects and the potential need to screen those with multiple cardiovascular risk factors prior to use of the triptans. Other disadvantages include dysgeusia as a side effect and that some patients may prefer an oral route of delivery.
- Many insurance plans require that those with migraine “try and fail” 1-2 triptans prior to using other newer acute medications (e.g., gepants, ditans and some older agents such as ergots).
- Do not use in the setting of coronary artery disease, unstable angina, hx of stroke, basilar-type or hemiplegic migraine, uncontrolled hypertension, vasculitides, including ischemic bowel disease.
- Limit use to 10 or fewer days per month to prevent medication overuse headache.
- Do not use in the setting of coronary artery disease, unstable angina, hx of stroke, basilar-type or hemiplegic migraine, uncontrolled hypertension, vasculitides, including ischemic bowel disease.
- Arrhythmias associated with cardiac accessory conduction pathway disorders, including Wolff-Parkinson-White syndrome
- Concomitant administration of MAO-A inhibitors or use within 2 weeks of discontinuation of MAO-A inhibitor therapy
- Concomitant use of ergotamine-containing or ergot-type medication (e.g., dihydroergotamine, methysergide) within 24 hours
- Concomitant use with a different triptan or ergot within 24 hours
- Coronary artery vasospasm, including Prinzmetal’s angina, or other significant underlying cardiovascular disease
- History of hemiplegic or basilar-type migraine
- History of stroke or transient ischemic attack
- Hypersensitivity to sumatriptan or any of its components
- Ischemic bowel disease
- Ischemic coronary artery disease (angina pectoris, history of myocardial infarction, or documented silent ischemia)
- Peripheral vascular disease
- Severe hepatic impairment
- Uncontrolled hypertension
- Click Onzetra® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- Do not use within 24 hours of another triptan or ergotamine
- Pharmacists frequently report a drug interaction between triptans and anti-depressants because of the risk of serotonin syndrome. However, this is felt to be a theoretical risk. Sufficient evidence to support the contention that combined use of triptans and serotonergic anti-depressants is unsafe has not been established. This is reflected in a position statement from the American Headache Society (Evans R. Headache 2010; 50: 1089-99) Therefore, headache physicians commonly co-administer antidepressants and triptans in the same patient.
- This product has a novel Xsail breath-powered delivery device.
- The Xsail device should be assembled, and the system is activated by a user’s breath. The user exhales into the assembled mouthpiece which automatically closes the soft palate and seals off the nasal cavity. Through a sealing nosepiece placed simultaneously into the nostril, the exhaled breath carries medication from the device directly into one side of the nose. As the medication is delivered, the air flows around to the opposite side of the nasal cavity and exits through the other nostril.
- After the patient takes a breath and blows out through the mouthpiece; one half of the initial dosage is administered into one single nostril.
- To deliver the remaining half of the initial dosage, the nosepiece should be replaced with a new one and inserted into the opposite nostril. The exhaled breath procedure is repeated to complete the delivery of the total 22mg initial dosage.
- May repeat dosage after 2 hours, if not pain free or adequate pain relief, limit to 2 doses, four sprays total, in 24 hours.
Zolmitriptan Intranasal (Zomig®) Click Here to Expand
Brands: Available Dosages:
- 2.5 mg and 5 mg nasal sprays
- 5 mg is most common dosage
- If patient has triptan intolerance, consider the 2.5 mg dosage
- One single spray in one nostril provides either a 2.5 mg dosage for the 2.5 mg nasal spray or a 5 mg dosage for the 5 mg nasal spray
- 5 mg for acute migraine attack, may repeat in 2 hours, if not pain free or adequate pain relief
- 10 mg
- Tightness in throat and chest, dizziness, or sedation/fatigue, tingling in the hands and feet
- A good choice as a primary therapy for migraine.
- May be used as rescue therapy in a person with persistent headache 2-24 hours after use of zolmitriptan tablets
- May also be a good alternative in patients that are “needle phobic”, but still need a fast onset of action.
- Zolmitriptan nasal spray has a faster onset of action than zomitriptan tablets.
- Triptans have a higher incidence of side effects than many NSAIDS and gepants. Side effects include paresthesias, neck tightness, chest pain/discomfort, dizziness and somnolence, which have been termed “triptan side effects”. Patients need to be warned of these side effects prior to their initial use. If not, some patients may delay use of triptans because of fear of these side effects.
- Zolmitriptan should not be used in those with known cardiovascular disease (CAD, stroke, Prinzmetal’s angina, peripheral vascular disease, mesenteric ischemia), hemiplegic migraine and basilar type migraine. It should be used with caution in those with two more cardiovascular risk factors. Some clinicians recommend cardiac evaluation to exclude unrecognized cardiovascular disease prior to use of sumatriptan or other triptans in patients who have two or more cardiovascular risk factors.
- Main advantages of zolmitriptan are good efficacy, a long safety record for use and multiple formulations to choose (e. tablets, ODT and nasal spray).
- Main disadvantages are a higher incidence of side effects and the potential need to screen those with cardiovascular or other vascular risks prior to use of the triptans.
- In addition, some patients may prefer an oral route of delivery.
- Many insurance plans require that those with migraine “try and fail” 1-2 triptans prior to using other newer acute medications (e.g., gepants, ditans and some older agents such as ergots).
- Do not use in the setting of coronary artery disease, unstable angina, hx of stroke, basilar type or hemiplegic migraine, uncontrolled hypertension, vasculitides, including ischemic bowel disease.
- Limit use to 10 or fewer days per month to prevent medication overuse headache.
- Arrhythmias associated with cardiac accessory conduction pathway disorders, including Wolff-Parkinson-White syndrome
- Concomitant administration of MAO-A inhibitors or use within 2 weeks of discontinuation of MAO-A inhibitor therapy
- Concomitant use of ergotamine-containing or ergot-type medication (e.g., dihydroergotamine, methysergide) within 24 hours
- Concomitant use with a different triptan or ergot within 24 hours
- Coronary artery vasospasm, including Prinzmetal’s angina, or other significant underlying cardiovascular disease
- History of hemiplegic or basilar type migraine
- History of stroke or transient ischemic attack
- Hypersensitivity to zolmitriptan or any of its components
- Ischemic bowel disease
- Ischemic coronary artery disease (angina pectoris, history of myocardial infarction, or documented silent ischemia)
- Peripheral vascular disease
- Severe hepatic impairment
- Uncontrolled hypertension
- Click Zomig® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- Do not use within 24 hours of another triptan or ergotamine
- Pharmacists frequently report a drug interaction between triptans and anti-depressants because of the risk of serotonin syndrome. However, this is felt to be a theoretical risk. Sufficient evidence to support the contention that combined use of triptans and serotonergic anti-depressants is unsafe has not been established. This is reflected in a position statement from the American Headache Society (Evans R. Headache 2010; 50: 1089-99) Therefore, headache physicians commonly co-administer antidepressants and triptans in the same patient.
- Keep head upright during administration and for 10-20 seconds after administration
- Do not lean forward or backward when administering or medication will run out the nose or into the mouth and not be absorbed
- Occlude the opposite nostril when administering
- Breath normally during administration; do not snort the medication or it will go in the posterior pharynx and later swallowed thus delaying absorption of medication
- One spray in one nostril, sit straight or lean nostril only slightly forward to administer and hold breath for seconds to allow absorption.
- May repeat dosage after 2 hours if not pain free or having adequate pain relief, limit to two doses in 24 hours