Instructions

You can use Zolmitriptan Nasal Spray as soon as a migraine headache starts. You can also use it once an attack is underway.

• The recommended dose is one spray (5 mg) in one nostril. It does not matter which nostril you use.

• You can use another spray if the migraine is still present after two hours or if it returns within 24 hours. If the nasal spray did not give you enough help with your migraine, tell your doctor. Your doctor may change your treatment. Do not use more than the dose prescribed for you.

• Do not use more than two spray doses in one day. 

• The maximum daily dose is 10 mg.

Full instructions in patient Information leaflet  Zolmitriptan Nasal spray

The following list is not exhaustive and we advise you to disclose all conditions and medicine you are currently taking so that our pharmacists can check for suitability before we make the supply to you.

• Concomitant administration of ergotamine, or derivatives of ergotamine (including methysergide) or any triptan/5-hydroxytryptamine1 (5-HT1) receptor agonist is contraindicated .

• Concurrent administration of reversible (e.g. moclobemide) or irreversible (e.g. selegiline) monoamine oxidase inhibitors (MAOIs) is contraindicated. Furthermore, triptan products must not be used within 2 weeks of discontinuation of therapy with MAOIs.

• Serotonin syndrome has been reported following the use of SSRIs and SNRIs at the same time as triptans.

• Rizatriptan: Plasma concentrations of rizatriptan may be increased by concomitant administration of propranolol. If you take propranolol, the 5 mg dose of Rizatriptan should be used .

• Eletriptan should not be used together with potent CYP3A4 inhibitors e.g., ketoconazole, itraconazole, erythromycin, clarithromycin, josamycin and protease inhibitors (ritonavir, indinavir and nelfinavir)  .

• Frovatriptan: There is a risk of hypertension and coronary artery constriction with concomitant use of frovatriptan and methylergometrine. Fluvoxamine is a potent inhibitor of cytochrome CYP1A2 and has been shown to increase the blood levels of frovatriptan by 27-49% .

• Zolmitriptan: A maximum dose of 5 mg zolmitriptan in 24 hours is recommended if you currently take cimetidine. Interactions with inhibitors of the cytochrome P450 isoenzyme CYP 1A2 cannot be excluded. Therefore, the same dosage reduction is recommended with compounds of this type, such as fluvoxamine and the quinolone antibiotics (e.g. ciprofloxacin)

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

Neurological symptoms

• Potentially serious neurological conditions should be excluded prior to treatment with triptans and further investigation may be recommended if you have atypical neurological symptoms or they are suggestive of a more  serious underlying cause of headache requiring emergency or urgent referral to secondary care.

Cerebrovascular events

• It should be noted that migraineurs may be at increased risk of certain cerebrovascular events (e.g. CVA, TIA).

Ischaemic heart disease

• Following administration, triptan products can be associated with transient symptoms including chest pain and tightness which may be intense and involve the throat. Where such symptoms are thought to indicate ischaemic heart disease, no further doses should be taken, and you should consult your GP.

Seizures • Sumatriptan should be used with caution if you have a history of seizures or other risk factors which lower the seizure threshold, as seizures have been reported in association with sumatriptan.

Medication overuse headache (MOH)

• 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 MOH should be suspected if you have frequent or daily headaches despite (or because of) the regular use of headache medication.

• As triptans taken as frequently as 10 days or more per month can result in medication overuse headache, you should not exceed this frequency of administration without supervision from your GP or specialist. Furthermore, we advise you to restrict the use of acute medication to a maximum of 2 days per week.

Ineffective treatment

• If treatment is ineffective on two or more treatment courses, you should consider seeing your GP . Poor response to triptans may be due to using triptans too little or too late in the attack, or, conversely, used too much (medication overuse).

Lactose

• Some triptan products may contain lactose, if you have rare hereditary problems of galactose-intolerance, the Lapp lactase deficiency or glucose-galactose- malabsorption. you should not take products. Check the product SmPC for specific content information.

Blood pressure

• Triptan products should be given with caution iif you have mild controlled hypertension, since transient increases in blood pressure and peripheral vascular resistance have been observed in a small proportion of people . It is recommended that you have your blood pressure measured before treatment with triptan products.

Angioedema

• Hypersensitivity reactions, including angioedema (e.g. facial oedema, tongue swelling and pharyngeal oedema) may occur in people treated with triptans. Treatment should be discontinued, and medical advice sought immediately if you suspect a hypersensitivity reaction.

Other considerations

• Triptan products should be administered with caution if you have a conditions that may affect the absorption, metabolism or excretion of the drug. If in any doubt, please make us aware so we can consult with the appropriate healthcare professional before approving the supply.

Migraine management

•Predisposing factors to Migraine should be identified and managed, though they may not always be avoidable.

Predisposing factors can include (but are not limited to): 

o Stress o Depression or anxiety o Menstruation o Menopause

• Identifying and avoiding trigger factors can reduce your frequency of attacks, though many attacks have no obvious trigger and those that are identified may not be avoidable .

• A headache diary may be used to record the frequency, duration, and severity of headaches, to monitor the effectiveness of treatment, and to use as a basis for discussion with your pharmcist or GP.

• For comprehensive guidelines on migraine management, see

Clinical Knowledge Summaries:

Treatment-summaries/migraine/