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Zolmitriptan

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Zolmitriptan, Zomig, Zomig ZMT

  • See Also
  1. Triptan
  2. Migraine Abortive Treatment
  3. Triptan Overdose
  • Indications
  • General
  1. Migraine Abortive Treatment (adults and children age 12 years and older)
  2. Cluster Headache (off-label except for Sumatriptan)
  3. Controversial cohorts in whom Triptan use is now thought safe (Cardiovascular Risk Factors)
    1. Controlled Diabetes Mellitus
    2. Controlled Hypertension
    3. Controlled Hyperlipidemia
    4. Postmenopausal women
    5. Men over age 40 years
  • Contraindications
  1. Children age <12 years
  2. Coronary Artery Disease
  3. Prinzmetal's Angina
  4. Uncontrolled Hypertension
  5. Basilar Artery Migraine
  6. Familial Hemiplegic Migraine
  7. Ischemic Cerebrovascular Accident
  8. Pregnancy
  9. Concurrent Medication use (absolute contraindications)
    1. MAO Inhibitor use
    2. Ergotamine use in prior 24 hours
  • Mechanism
  1. Serotonergic 5-HT1 receptor Agonists
  2. Inhibits sensory dural nerve fiber neuropeptide release
  3. Intracranial extracerebral artery Vasoconstriction
    1. Mediated by Triptan direct effect on cerebrovascular Smooth Muscle
  • Precautions
  1. Screen for cardiovascular disease before use!
  2. Limit to no more than twice weekly
  • Medications
  1. Zolmitriptan (Zomig)
    1. Oral: 2.5 mg, 5 mg
    2. Oral disintegrating tablets (ZMT): 2.5 mg, 5 mg
    3. Intranasal: 2.5 mg or 5 mg per spray
  • Dosing
  1. Indicated for Migraine Headaches in adults and children age 12 years and older
  2. Oral (standard or disintegrating ZMT)
    1. Initial: 1.25 to 2.5 mg orally (up to maximum single dose of 5 mg)
    2. May repeat dose every 2 hours as needed
    3. Maximum: 10 mg in 24 hours
  3. Intranasal
    1. Dose: 2.5 to 5 mg spray (single dose unit)
    2. Onset: 15 minutes (faster than oral preparations)
    3. May repeat dose every 2 hours as needed
    4. Maximum: 10 mg in 24 hours
  4. Moderate to severe hepatic Impairment
    1. Do NOT use disintegrating ZMT or intranasal formulations
    2. Reduce oral dosing to 1.25 mg/dose (maximum total of 2.5 mg in 24 hours)
  • Adverse Effects
  1. See Triptan Overdose
  2. Intranasal preparations
    1. Dysgeusia (Terrible taste)
  3. Vasospasm
    1. Generally benign in low risk populations
    2. Avoid in Coronary Artery Disease, Cerebrovascular Disease, Peripheral Arterial Disease
    3. Also avoid in hemiplegic Migraine or basilar Migraine
  4. Medication Overuse Headaches
    1. Highest risk with >10 doses per month
    2. Limit to two doses weekly
  • Safety
  1. Unknown safety in Lactation
  2. Pregnancy Category C (most Triptans, but generally avoided in pregnancy)
    1. See Migraine Medications in Pregnancy
    2. Not recommended for routine use in pregnancy
    3. Consult obstetrics before use
    4. May be considered if Migraines are uncontrolled, debilitating
      1. If used, Sumatriptan has the longest safety data
    5. Adverse effects in pregnancy
      1. Avoid in first trimester (fetal malformations and adverse pregnancy outcomes)
      2. Risk of uterine atony and peripartum Hemorrhage (but may be considered in debilitating Headache)
      3. Associated with hyperactivity and emotionality at age 3 in exposed children (AHRQ)
    6. References
      1. Nezvalova-Henriksen (2010) Headache 50(4): 563-75 +PMID: 20132339 [PubMed]
  • Drug Interactions
  1. Cimetidine
    1. Limit Zolmitriptan individual total doses to 2.5 mg (5 mg in 24 hours)
  2. See absolute contraindications above
    1. Ergotamine
    2. MAO Inhibitors
  3. Lithium
  4. Selective Serotonin Reuptake Inhibitor (SSRI)
    1. Risk of Serotonin Syndrome when combined with SSRI, SNRI or MAO Inhibitors
  1. See Triptan Overdose
  • Resources
  1. Zolmitriptan (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=333caafc-2e63-49f8-a0c6-534e528d228d
  2. Triptans (StatPearls)
    1. https://www.ncbi.nlm.nih.gov/books/NBK554507/
  3. Where do Triptans act in the treatment of Migraine? (PMC)
    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1850935/
  • References
  1. Jamieson (2002) Am J Med 112:138 [PubMed]
  2. Ahn (2005) Pain 115(1-2):1-4 +PMID: 15836963 [PubMed]