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Ask the Pharmacist: Limits of Sumatriptan for Cluster a Matter of Debate

Q. I’m a cluster sufferer and often use injectable sumatriptan pens several times daily during my worst bouts. It’s the only thing that works. But my local pharmacy and my insurance company give me grief about the amount of sumatriptan I use, meaning I have to pay out of my own pocket. Am I using too much sumatriptan?

A. I suspect the limits of sumatriptan imposed by your insurance company are based on recommendations for migraine treatment, not cluster treatment. I am not aware of any research that definitively states how much sumatriptan is too much for your condition, and this important question is often a matter of debate among headache specialists. Furthermore, the severe, rapid pain that characterizes cluster attacks is well known, but we do not know what risks, if any, exist with repeated sumatriptan use. This raises ethical questions regarding the withholding of an effective medication from individuals in extreme pain.

There are several actions you can take to help yourself. Though the sumatriptan autoinjector (“pen”) is designed to be easy to use, it delivers 6 mg of medication per dose. Many cluster patients can obtain relief with only 2 mg or 3 mg and do not need the whole 6 mg. I would encourage you to ask for vials of sumatriptan at you local pharmacy, instead of the pen. You will need to learn how to draw up medication into syringes, but you will then have the option of administering a smaller but still effective dose. As a result, you’ll have two or three doses at your disposal.

Once you puncture the vial, it’s important that you dispose of it after 24 hours, even if some medication remains, to avoid contamination. Since cluster patients generally have multiple daily attacks, leftover medication is a rare occurrence. You can also ask your physician to write a letter of appeal to your insurance company, explaining your condition, your treatment and the lack of information regarding limits on sumatriptan. Once educated, your insurance company should be more willing to assist you.

Finally, you do not state whether you take any medication to prevent your cluster attacks. This is another option to reduce the frequency of your cluster headaches, thereby reducing your need for sumatriptan.

GelStat Promising, But Needs More Study

Q. I heard of a treatment for migraines called GelStat. Can you tell me anything about this drug?

A. GelStat is a newer, over-the-counter combination product that contains several ingredients, notably feverfew, a substance that has been shown beneficial for some migraine sufferers. GelStat is taken sublingually (under the tongue), which may allow the drug to be absorbed into the bloodstream more rapidly.

I am aware of only one study with GelStat, which examined the product’s effectiveness in only 30 people. Since migraine affects 28 million individuals, drawing conclusions from such a small study may not be wise, regardless of the study’s positive results. More research (which the company is currently conducting) is needed before the proper role of this product in migraine therapy is understood.

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