100 Migraine Drugs, A to Z: zolmitriptan
Zolmitriptan (Zomig, Zomig ZMT, Zomig NS) is one of seven triptans sold in the US. It is available in tablets, orally disintegrating tablets, and nasal spray. The nasal spray is approved for children 12 and older. Both tablets and the spray are available in 2.5 mg and 5 mg strength. The maximum daily dose is 10 mg.
However, it is washed out of the body within a few hours. This means that taking three 5 mg tablets spread out over 24 hours poses no danger. Three doses a day is the approved limit for rizatriptan (Maxalt). There is no reason why this should not apply to zolmitriptan and other triptans except for the long-lasting frovatriptan. Fortunately, it is uncommon that a patient requires three doses in one day. And if a patient does need to take a triptan more than twice a day, we usually try a different drug that may work with a single dose.
One advantage of the nasal spray is that it tends to have a faster onset of action. Another advantage is that can be taken when severe nausea or vomiting precludes the use of oral medications. My impression is that zolmitriptan spray is more effective than the original sumatriptan spray. The amount of fluid in a single dose of Zomig is less than that in sumatriptan and the spray droplets are of smaller size. This leads to better retention of fluid in the nasal passages and better absorption.
The new version of sumatriptan spray, Tosymra contains 10 mg of sumatriptan while the original spray contains 20 mg. However, it comes out in smaller droplets and contains an ingredient that allows for better absorption. This formulation of sumatriptan spray appears to be as effective as Zomig NS.
Zolmitriptan nasal spray is expensive (as is Tosymra) because it is available only as a branded product. It will lose its patent protection in 2021.
Sumatriptan and zolmitriptan are available in a nasal spray form. The original sumatriptan spray is not very effective due to the high volume of liquid and large droplets that come out. There is a new formulation of this spray (Tosymra) with half of the dose but much better absorption. It is very expensive though. Zolmitriptan nasal spray (Zomig NS) is also well absorbed. But many people find nasal sprays completely ineffective or irritating to their nasal passages. Suppositories of sumatriptan were never released in the US but is a good formulation for those with nausea. I also prescribe suppositories of nausea drugs such as prochlorperazine (Compazine) and promethazine (Phenergan). These help not only nausea but also pain. They also, by relieving nausea, allow you to take a pill of sumatriptan or another medication.
A doctor once told me that when you use nasal spray triptans, only part of it is absorbed in the nose, the rest goes down to the stomach. Could you give some information about this?
Imigran suppositories have been my rescue and I have saved what I had left when they were out of production. The best before date was June 2016 but I used one today, January 30th 2021, and it still had some effect! It stops the nausea and makes my body absorb oral medication. I have only two left now. Nasal spray triptans seems to be my next option, but I have tried it before and I didn’t really like it.