4.1. Therapeutic indications

Sumatriptan is indicated for the acute relief of migraine attacks, with or without, aura, including acute migraine attacks associated with menstruation.

Sumatriptan should only be used where there is a clear diagnosis of migraine.

4.2. Posology and method of administration

Posology

Adults

Sumatriptan is indicated for the acute intermittent treatment of migraine. It should not be used prophylactically. The recommended dose of sumatriptan should not be exceeded.

It is advisable that sumatriptan be given as early as possible after the onset of a migraine attack, but it is equally effective at whatever stage of the attack it is administered.

The recommended dose of oral sumatriptan is a 50 mg tablet. Some patients may require 25 mg or 100 mg. The tablet cannot be divided into two equal doses; if necessary, the use of other medicinal product with the same active ingredient, dosage and pharmaceutical form available in divisible tablet should be considered. If the patient has responded to the first dose, but the symptoms recur a second dose may be given provided that there is a minimum interval of two hours between the two doses. No more than 300 mg should be taken in any 24-hour period.

Patients who do not respond to the prescribed dose of sumatriptan should not take a second dose for the same attack. In these cases, the attack can be treated with paracetamol, acetylsalicylic acid or non- steroidal anti-inflammatory drugs. Sumatriptan may be taken for subsequent attacks.

Sumatriptan is recommended as monotherapy for the acute treatment of migraine and should not be given concomitantly with ergotamine or derivatives of ergotamine (including methysergide) (see section 4.3).

Paediatric population

The efficacy and safety of sumatriptan film-coated tablets in children aged less than 10 years have not been established. No clinical data are available in this age group.

The efficacy and safety of sumatriptan film-coated tablets in children 10 to 17 years of age have not been demonstrated in the clinical trials performed in this age group. Therefore, the use of sumatriptan film-coated tablets in children 10 to 17 years of age is not recommended (see section 5.1).

Elderly (over 65 years of age)

Experience of the use of sumatriptan in patients aged over 65 years is limited. The pharmacokinetics do not differ significantly from a younger population, but until further clinical data are available, the use of sumatriptan in patients aged over 65 years is not recommended.

Hepatic impairment

Dosage adjustment is necessary in these patients (see sections 4.4 and 5.2).

Method of administration

The tablets should be swallowed whole with water.

4.3. Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1 Sumatriptan should not be given to patients who have had myocardial infarction or have ischaemic heart disease, coronary vasospasm (Prinzmetal's angina), peripheral vascular disease or patients who have symptoms or signs consistent with ischaemic heart disease.

Sumatriptan should not be administered to patients with a history of cerebrovascular accident (CVA) or transient ischaemic attack (TIA).

Sumatriptan should not be administered to patients with severe hepatic impairment.

The use of sumatriptan in patients with moderate and severe hypertension and mild uncontrolled hypertension is contraindicated.

Concurrent administration of reversible and irreversible monoamine oxidase inhibitors and sumatriptan is contraindicated. Sumatriptan tablets must not be used within two weeks of discontinuation of therapy with monoamine oxidase inhibitors.

The concomitant administration of ergotamine or derivatives of ergotamine (including methysergide) or any triptan/5-hydroxytryptamine1 (5-HT1) receptor agonist or lithium with sumatriptan is contraindicated (see section 4.5).

4.4. Special warnings and precautions for use

Sumatriptan should only be used where there is a clear diagnosis of migraine.

Sumatriptan is not indicated for use in the management of hemiplegic, basilar or opthalmoplegic migraine.

Before treating with sumatriptan, care should be taken to exclude potentially serious neurological conditions, e.g. cerebrovascular accident (CVA), transient ischaemic attack (TIA), if the patient presents with atypical symptoms or if they have not received an appropriate diagnosis for sumatriptan use.

Following administration, sumatriptan can be associated with transient symptoms including chest pain and tightness, which may be intense and involve the throat (see section 4.8). Where such symptoms are thought to indicate ischaemic heart disease, no further doses of sumatriptan should be given and appropriate evaluation should be carried out.

Sumatriptan should not be given to patients with risk factors for ischaemic heart disease, including those patients who are diabetics, heavy smokers or users of nicotine substitution therapies, without prior cardiovascular evaluation (see section 4.3). Special consideration should be given to postmenopausal women and males over 40 with these risk factors. These evaluations, however, may not identify every patient who has cardiac disease, and, in very rare cases, serious cardiac events have occurred in patients without underlying cardiovascular disease.

Sumatriptan should be administered with caution to patients with mild controlled hypertension, since transient increases in blood pressure and peripheral vascular resistance have been observed in a small proportion of patients (see section 4.3).

There have been rare post-marketing reports describing patients with serotonin syndrome (including altered mental status, autonomic instability and neuromuscular abnormalities) following the use of a selective serotonin reuptake inhibitor (SSRI) and sumatriptan. Serotonin syndrome has been reported following concomitant treatment with triptans and serotonin noradrenaline reuptake inhibitors (SNRIs).

If concomitant treatment with sumatriptan and an SSRI/SNRI is clinically warranted, appropriate observation of the patient is advised (see section 4.5).

Sumatriptan should be administered with caution to patients with conditions which may affect significantly the absorption, metabolism or excretion of drugs, e.g. impaired hepatic (see section 5.2) or renal function (see section 5.2).

Patients with known hypersensitivity to sulfonamides may exhibit an allergic reaction following administration of sumatriptan. Reactions may range from cutaneous hypersensitivity to anaphylaxis. Evidence of cross-sensitivity is limited, however, caution should be exercised before using sumatriptan in these patients.

Undesirable effects may be more common during concomitant use of triptans and herbal preparations containing St. John's wort (Hypericum perforatum).

Sumatriptan should be used with caution in patients with epilepsy and/or a history of seizures or other risk factors which lower the seizure threshold, as seizures have been reported in association with sumatriptan (see section 4.8).

Prolonged use of any type of painkiller for headaches can make them worse. If this situation is experienced or suspected, medical advice should be obtained and treatment should be discontinued. The diagnosis of medication overuse headache (MOH) should be suspected in patients who have frequent or daily headaches despite (or because of) the regular use of headache medication.

Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose- galactose malabsorption should not take this medicine.

This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially 'sodium free'.

4.5. Interaction with other medicinal products and other forms of interaction

Studies in healthy subjects show that sumatriptan does not interact with propranolol, flunarizine, pizotifen or alcohol.

Preparations containing ergotamine or other triptans/5-HT1 receptor agonists may lead to prolonged vasospastic reactions. There is limited data relating to interactions with these preparations. The increased risk of coronary artery spasm is a theoretical possibility, therefore concomitant administration is contraindicated (see section 4.3).

The period of time that should elapse between the use of sumatriptan and ergotamine-containing preparations or another triptan/5-HT1 receptor agonist is not known. This will also depend on the doses and types of products used. The effects may be additive. It is advised to wait at least 24 hours following the use of ergotamine-containing preparations or another triptan/5-HT1 receptor agonist before administering sumatriptan. Conversely, it is advised to wait at least 6 hours following use of sumatriptan before administering an ergotamine-containing product and at least 24 hours before administering another triptan/5-HT1 receptor agonist.

An interaction may occur between sumatriptan and monoamine oxidase inhibitors (MAOIs) and concomitant administration is contraindicated (see section 4.3).

There have been rare post-marketing reports describing patients with serotonin syndrome (including altered mental status, autonomic nervous system imbalance and neuromuscular abnormalities) following the use of SSRIs and sumatriptan. Serotonin syndrome has also been reported following concomitant treatment with triptans and SNRIs (see section 4.4).

There may be a risk of serotonergic syndrome also if sumatriptan is used concomitantly with lithium.

4.6. Fertility, pregnancy and lactation

Pregnancy

Post-marketing data from the use of sumatriptan during the first trimester in over 1,000 women are available. Although these data contain insufficient information to draw definitive conclusions, they do not point to an increased risk of congenital defects. Experience with the use of sumatriptan in the second and third trimester is limited.

Evaluation of experimental animal studies does not indicate direct teratogenic effects or harmful effects on peri- and postnatal development. However, embryonic and foetal death may occur in rabbits (see section 5.3).

Administration of sumatriptan should only be considered if the expected benefit to the mother is greater than any possible risk to the foetus.

Breast-feeding

Sumatriptan is secreted into breast milk, with average relative infant doses of <4% following administration of a single dose of sumatriptan. Infant exposure can be minimised by avoiding breast feeding for 12 hours after treatment, during which time any breast milk expressed should be discarded.

There have been reports of breast pain and/or nipple pain following sumatriptan use in breast- feeding women (see section 4.8). The pain was usually transient and disappeared in 3 to 12 hours.

4.7. Effects on ability to drive and use machines

No studies on the effects on the ability to drive and use machines have been performed. Somnolence and dizziness or other related symptoms either due to the migraine or treatment with sumatriptan may occur. This may influence the ability to drive and to operate machinery.

Caution is recommended for patients engaged in such activities.

4.8. Undesirable effects

Adverse events are listed below by system organ class and frequency. Frequencies are defined as: very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1000 to <1/100), rare (≥1/10,000 to <1/1000), very rare (<1/10,000), not known (cannot be estimated from the available data). Some of the symptoms reported as undesirable effects may be associated symptoms of migraine.

Immune system disorders

Not known:

Hypersensitivity reactions ranging from cutaneous hypersensitivity (such as urticaria) to anaphylactic reactions.

Psychiatric disorders

Not known:

Anxiety.

Nervous system disorders

Common:

Dizziness, somnolence, sensory disturbance including paraesthesia and hypoaesthesia.

Not known:

Seizures, although 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. Tremor, dystonia, nystagmus, visual field defect.

Eye disorders

Not known:

Flickering, diplopia, reduced vision. Loss of vision including reports of permanent defects. However, visual impairment may also occur during a migraine attack itself.

Cardiac disorders

Not known:

Bradycardia, tachycardia, palpitations, cardiac arrhythmias, transient ischaemic ECG changes, coronary artery vasospasm, angina pectoris, myocardial infarction (see sections 4.3 and 4.4).

Vascular disorders

Common:

Transient increases in blood pressure arising soon after treatment. Flushing.

Not known:

Hypotension, Raynaud's phenomenon. Respiratory, thoracic and mediastinal disorders

Common:

Dyspnoea.

Gastrointestinal disorders

Common:

Nausea and vomiting occurred in some patients, but it is unclear if this is related to sumatriptan or the underlying condition.

Not known:

Ischaemic colitis, diarrhoea, dysphagia. Skin and subcutaneous tissue disorders

Not known:

Hyperhidrosis.

Musculoskeletal and connective tissue disorders

Common:

Sensations of heaviness (usually transient and may be intense and can affect any part of the body including the chest and throat). Myalgia.

Not known:

Neck stiffness, arthralgia.

Reproductive system and breast disorders

Rare:

Breast pain.

General disorders and administration site conditions

Common:

Pain, sensations of heat or cold, pressure or tightness (these events are usually transient and may be intense and can affect any part of the body including the chest and throat); feelings of weakness, fatigue (both events are mostly mild to moderate in intensity and transient).

Not known:

Pain trauma activated, pain inflammation activated. Investigations

Very rare:

Minor disturbances in liver function tests have occasionally been observed.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme.

Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

Symptoms of Overdose

Oral doses up to 100 mg were not associated with side effects other than those mentioned.

Treatment

In cases of overdose, the patient must be monitored for at least 10 hours and if necessary, standard supportive treatment must be given.

There is no information on the effect of haemodialysis or peritoneal dialysis on plasma sumatriptan concentrations.