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.

Verapamil (Calan, Isoptin) is an effective drug for the prevention of cluster headaches. It is sometimes used for migraines as well. However, the evidence for its efficacy is weak. A double-blind crossover trial by Dr. Glen Solomon and his colleagues in Ohio examined the effect of 320 mg of verapamil on 12 migraine patients. The drug was more effective than the placebo. Other small studies also suggested that it might help some patients.

Verapamil has a reputation among headache specialists as being effective for the prevention of frequent migraine auras and other neurological symptoms that occur with migraines. Unfortunately, there are no controlled trials to support this impression.

The starting dose of verapamil is 120 mg a day with a possible escalation up to 480 mg. For cluster headaches, the starting dose is 240 mg and the maximum dose is as high as 960 mg. Verapamil can cause arrhythmia (irregular heartbeat), especially at higher doses. I recommend an electrocardiogram before every increase of the dose above 240 mg.

The two most common side effects of verapamil are constipation and swelling of the feet. In some of my patients, constipation was severe and resistant to treatment. They had to stop taking the drug.