Zolmitriptan (Zomig) for the acute treatment of migraine

The trigeminal system's sensory neurons and cranial arteries both include serotonin 5-HT-1B and 5-HT-1D receptors, and zolmitriptan is a selective agonist for these receptors. faq id="7198" select-faq The following disorders are listed among those for which it is indicated:

  • For the quick treatment of migraines in those over the age of 12 with or without aura

  • Off Label Uses of Zolmitriptan in Adults include:

    • Treatment of Cluster headache

    • For the short-term prevention of menstrual migraines

Zolmitriptan Dose in Adults

Dose as off-label use in the treatment of Cluster headache:

  • Nasal inhalation or oral tablets:
    • With the first sign of a cluster headache, the typical dose ranges from 5 to 10 mg, with a 10 mg maximum dose per dose.

Dose in the treatment of Migraine:

  • Nasal inhalation:
    • 2.5 mg to a maximum of 5 mg per dosage
  • Tablet:
    • 1.25–2.5 mg orally, with a 5 mg maximum single dose.
  • Orally disintegrating tablet:
    • 2.5 mg orally to a maximum single dose of 5 mg
    • A second dose may be repeated in 2 hours up to a maximum dose of 10 mg/day if the patient does not respond to the first dose or the headache returns after transient improvement.

Dose as off-label use in the prophylaxis of Menstrual migraine:

  • 5 mg orally 2 - 3 times a day.
  • For a total of seven days, it should be begun two days prior to the start of menstrual cycles and continued for up to five days following the start of menses.
  • Dosing adjustment for concomitant therapy with cimetidine:

    • A single dose of no more than 2.5 mg or 5 mg per day should be used.

Zolmitriptan Dose in Children

Dose in the treatment of Migraine in children:

  • Children older than 12 years and Adolescents:
    • Intranasal administration:
      • 2.5 mg initially.
      • The dose may be titrated based on the patient's response to a maximum single dose of 5 mg.
      • It should be administered at the onset of symptoms.
      • A second dose may be repeated in 2 hours up to a maximum dose of 10 mg/day if the patient does not respond to the first dose or the headache returns after transient improvement.
  • Dosing adjustment for concomitant therapy with cimetidine:

    • A maximum single dose of 2.5 mg or 5 mg per day should not be exceeded.

Pregnancy Risk Factor: C

  • It is not known if any data are available.
  • This should be avoided, and other agents should be used.
  • Particularly if adverse fetal outcomes are observed, inadvertent exposure should also be reported.

Zolmitriptan use during breastfeeding:

  • Excretion of the drug into breastmilk is not known.
  • The manufacturer advises weighing the benefits and risks of its use in both the infant and the nursing mother.
  • Other safer agents should be preferably used.

Zolmitriptan dose in Kidney disease:

The manufacturer does not recommend any dose adjustment in patients with kidney disease, however, clearance is impaired with a CrCl of less than 25 ml/min. 

Zolmitriptan dose in Liver disease:

Tablet formulation:

  • Mild impairment:
    • No adjustment in the dose is required.
  • Moderate to severe impairment:
    • Initiate therapy with 1.25 mg to a maximum daily dose of 5 mg in severe hepatic impairment.

Orally disintegrating tablet:

  • Mild impairment:
    • No adjustment in the dose is required.
  • Moderate to severe impairment:
    • Avoid its use.

Nasal inhalation:

  • Mild impairment:
    • No adjustment in the dose is necessary.
  • Moderate to severe:
    • Avoid its use.

Common Side Effects of Zolmitriptan Include:

  • Gastrointestinal:
    • Unpleasant taste

Less Common Side Effects of Zolmitriptan Include:

  • Cardiovascular:
    • Chest Pain
    • Chest Pressure
    • Facial Edema
    • Palpitations
    • Cardiac Arrhythmia
    • Hypertension
    • Syncope
    • Tachycardia
  • Central Nervous System:
    • Dizziness
    • Paresthesia
    • Drowsiness
    • Local Alterations In Temperature Sensations
    • Sensation Of Pressure
    • Hyperesthesia,
    • Flushing Sensation
    • Pain
    • Vertigo
    • Chills
    • Depersonalization
    • Headache
    • Agitation
    • Amnesia
    • Anxiety
    • Depression
    • Emotional Lability
    • Insomnia
    • Nervousness
  • Dermatologic:
    • Diaphoresis
    • Pruritus
    • Skin Rash
    • Urticaria
  • Gastrointestinal:
    • Nausea
    • Xerostomia
    • Dyspepsia
    • Dysphagia
    • Abdominal Pain
    • Vomiting
  • Genitourinary:
    • Urinary Frequency
    • Urinary Urgency
  • Hypersensitivity:
    • Hypersensitivity Reaction
  • Local:
    • Local Pain
    • Application Site Irritation
  • Neuromuscular & Skeletal:
    • Weakness
    • Arthralgia
    • Myalgia
  • Otic:
    • Tinnitus
  • Renal:
    • Polyuria
  • Respiratory:
    • Nasal Discomfort
    • Constriction Of The Pharynx
    • Pressure On Pharynx
    • Bronchitis
    • Cough
    • Dyspnea
    • Epistaxis
    • Laryngeal Edema
    • Pharyngitis
    • Rhinitis
    • Sinusitis

Contraindication to Zolmitriptan Include:

  • Allergy reactions to zolmitriptan and any component of the formulation
  • Angina pectoris, myocardial injury, or history of myocardial injury, is an example of ischemia.
  • Vasospasm of the Coronary Artery, including Prinzmetal-type angina
  • Wolff-Parkinson-White syndrome or arrhythmias secondary to cardiac accessory conduction pathway
  • Peripheral Vascular Disease
  • Ischemic bowel disease
  • Hypertension uncontrolled
  • Concomitant with another 5-HT agonist, ergotamine-containing or ergot-type medication like dihydroergotamine or methysergide
  • History of stroke, transient ischemic attacks, or basilar, hemiplegic, or ophthalmoplegic headaches.
  • Usage of zolmitriptan in conjunction with monoamine oxidase A (MAO) inhibitors within 14 days of discontinuing MAO-A inhibitor therapy
  • Heart disease of the valvular kind

Warnings and Precautions

  • Cardiac events:
    • Zolmitriptan can cause vasoconstriction.
    • Myocardial damage, myocardial ischemia, ventricular arrhythmias such fibrillation and ventricular tachycardia, cardiac arrest, and even death could result from it.
    • Patients suffering from vasospastic or coronary artery disease should not use it.
    • Likewise, patients with Prinzmetal's variant angina, WPW (Wolff-Parkinson-White) Syndrome, and those with conduction defects should also avoid using it.
    • Patients with chest pain or tightness symptoms should be evaluated by a physician. If the patient is not responding to treatment, he/she may be asked to stop taking medication.
  • Cerebrovascular events
    • Zolmitriptan has been linked to strokes and subarachnoid hemorhage in the brain.
    • Patients who have suffered from stroke or TIA should not use it.
  • High blood pressure
    • Zolmitriptan should not be prescribed to patients with uncontrolled hypertension.
    • Blood pressure spikes, including hypertensive crises, can occur in patients with managed hypertension as well as occasionally in those without a history of the condition.
  • Vasospasm-related events
    • It has been associated with Vasospastic episodes, including gastrointestinal vascular and peripheral ischemia.
    • Infarctions presenting with bloody diarrhea, abdominal pain, and splenic injury, as well as Raynaud syndrome, have been reported.
    • Patients who have clinical signs that suggest a vasospastic disorder should receive the lowest dose possible.
  • Visual effects
    • It has been reported that temporary (rarely permanent!) visual impairments have been caused by its use.
  • Coronary artery disease
    • Patients at high risk for coronary artery disease should not be given the drug.
    • These patients are at high risk for developing CAD:
      • Hypertension
      • Hypercholesterolemia
      • Smoker
      • Obesity
      • Diabetes
      • Strong family history of coronary heart disease
      • Menopause
      • Males over 40 years old are considered older.
    • It is important to evaluate patients who have been diagnosed with coronary artery disease before administering the medication. The first dose should be administered in a hospital.
    • Regular evaluations of patients should be done for CAD.
  • Hepatic impairment
    • Patients with hepatic impairment need to be cautious as drug clearance can be impaired in patients suffering from liver disease.
    • The nasal spray and oral disintegrating tablets should not be used by patients who have liver problems.
    • The dosage of their oral pills may need to be adjusted for patients with severe or moderate hepatic impairment.

Zolmitriptan: Drug Interaction

Risk Factor C (Monitor therapy)

Antiemetics (5HT3 Antagonists)

Could make serotonin modulators' serotonergic effects stronger. Serotonin syndrome might occur from this.

Antipsychotic Agents

Serotonin modulators might make antipsychotic drugs more harmful or toxic. Serotonin modulators, in particular, may enhance dopamine blockade, potentially raising the risk for neuroleptic malignant syndrome. Serotonin modulators' serotonergic effects may be strengthened by antipsychotic drugs. Serotonin syndrome might occur from this.

Droxidopa

Droxidopa's hypertensive action may be enhanced by serotonin 5-HT1D receptor antagonists.

Metaxalone

Could make serotonin modulators' serotonergic effects stronger. Serotonin syndrome might occur from this.

Methylphenidate

Serotonin modulators' harmful or toxic effects could be exacerbated. In particular, there may be an increased risk of serotonin syndrome or serotonin poisoning.

Metoclopramide

Serotonin modulators may intensify Metoclopramide's harmful or hazardous effects. These could appear as signs of neuroleptic malignant syndrome or serotonin syndrome.

Opioid Agonists

Could make serotonin modulators' serotonergic effects stronger. Serotonin syndrome might occur from this.

Propranolol

ZOLMitriptan serum concentration can rise.

Serotonin Modulators

The negative or hazardous effects of other serotonin modulators might be increased. Serotonin syndrome may start to develop. Nicergoline and Tedizolid are exceptions.

TraMADol

Serotonin modulators may intensify TraMADol's harmful or hazardous effects. Seizures may become more likely. The serotonergic impact of serotonin modulators may be enhanced by TraMADol. Serotonin syndrome might occur from this.

Risk Factor D (Consider therapy modification)

Cimetidine

ZOLMitriptan serum concentration can rise. When given in conjunction with cimetidine, the maximum single dose of zolmitriptan should be 2.5 mg, and the maximum daily dose should not exceed 5 mg.

Risk Factor X (Avoid combination)

Dapoxetine

Serotonin modulators' harmful or toxic effects could be exacerbated.

Ergot Derivatives

May enhance serotonin 5-HT1D receptor antagonists' ability to constrict blood vessels. The vasoconstrictive effects of ergot derivatives may be enhanced by serotonin 5-HT1D receptor antagonists. Exceptions: Nicergoline.

Methylene Blue

Could make serotonin modulators' serotonergic effects stronger. Serotonin syndrome might occur from this.

Monoamine Oxidase Inhibitors

May slow down the metabolism of substances that block serotonin 5-HT1D receptors. Management: Naratriptan, eletriptan, or frovatriptan may be suitable 5-HT1D agonists to use if MAO inhibitor medication is necessary.

SUMAtriptan

The negative/toxic effects of sumatriptan may be increased by serotonin 5-HT1D receptor antagonists.

Monitor:

  • The severity of the headache.
  • Clinical features of angina especially in patients at risk.
  • Blood pressure in hypertensive patients.
  • ECG in patients at risk (with the first dose )

How to administer Zolmitriptan?

  • It should be administered immediately the migraine symptoms are apparent.
  • TheTabletIf a lower initial dose is needed, the dosage can be divided in half.
  • TheOrally-disintegrating tabletIt must be consumed whole. It must not be broken or crushed.
  •  It should not be mixed with liquids. However, it can be placed on the tongue to dissolve.
  • Before you use the nasal sprayGently blow your nose. 
  • Remove the protective cap, and instill the device directly into the nostril. 
  • Block the opposite nostril, and inhale gently while pushing the plunger of this device. 

Mechanism of action of Zolmitriptan:

  • It acts as a selective antagonist for serotonin 5-HT-1B or 5-HT-1D receptors, which are found in the cranial vessels and sensory nerves of trigeminal systems.
  • It decreases inflammation due to antidromic neural transmission, and causes vasoconstriction. This can relieve the symptoms of migraine.

It is well absorbed.

25% of the drug is protein-bound.

It is metabolized to the more active compound N-N-desmethyl metabolite.

It has been abioavailabilityAfter oral intake, the average bioavailability of the nasal spray is 40% The nasal spray has a higher mean bioavailability than the oral tablet (102%).

It has been a half-life eliminationapproximately 3 hours, and the time topeak serum concentrationThe oral tablet takes approximately 1.5 hours to complete.

60-65% of the drug areexcretedIt is found in the urine, and 30% of it is excreted by the feces.

International Brands of Zolmitriptan:

  • AG-Zolmitriptan
  • APO-Zolmitriptan
  • APO-Zolmitriptan Rapid
  • CCP-Zolmitriptan
  • DOM-Zolmitriptan
  • JAMP-Zolmitriptan
  • JAMP-Zolmitriptan ODT
  • Mar-Zolmitriptan
  • MINT-Zolmitriptan
  • MINT-Zolmitriptan ODT [DSC]
  • MYLAN-Zolmitriptan ODT [DSC]
  • MYLAN-Zolmitriptan [DSC]
  • NAT-Zolmitriptan
  • PMSZolmitriptan
  • PMS-Zolmitriptan ODT
  • RIVA-Zolmitriptan [DSC]
  • SANDOZ Zolmitriptan
  • SANDOZ Zolmitriptan ODT
  • Septa Zolmitriptan-ODT
  • TEVA-Zolmitriptan
  • TEVA-Zolmitriptan OD
  • VANZolmitriptan ODT
  • Zomig
  • Zomig Rapimelt
  • Ascotop
  • Emicrania
  • Heng Li An
  • Miotrol
  • Myslee
  • Nomi
  • Olatrip
  • Rapimig
  • Zolan
  • Zolmigo
  • Zolmigren
  • Zolmiles
  • Zolmist
  • Zolmit
  • Zoltrip
  • Zomig
  • Zomig Rapimelt
  • Zomig ZMT
  • Zomigon
  • Zomigoro
  • Zomiles
  • Zomitan

Zolmitriptan in Pakistan:

Zolmitriptan 2.5 Mg In Pakistan

Brand

Pharmaceutical Company

Akpran Akhai Pharmaceuticals.
Engzol English Pharmaceuticals Industries
Limigzol Genetics Pharmaceuticals
Mig-2.5 Csh Pharmaceuticals-North (Pvt) Ltd
Migzor Hilton Pharma (Pvt) Limited
Mitprix Alliance Pharmaceuticals (Pvt) Ltd.
Olmig Dyson Research Laboratories
Zintin Elko Organization (Pvt) Ltd.
Ziptan Medisure Laboratories Pakistan (Pvt.) Ltd.
Zolimit Genome Pharmaceuticals (Pvt) Ltd
Zolmitra Amarant Pharmaceuticals (Pvt)
Zolser Panacea Pharmaceuticals
Zomig ICI Pakistan Ltd.
Zominat Bio Pharma
Zomip Ferroza International Pharmaceuticals (Pvt) Ltd.
Zomoz Wilshire Laboratories (Pvt) Ltd.

Zolmitriptan 2.5 Mg In Pakistan

Brand

Pharmaceutical Company

Engzol English Pharmaceuticals Industries
Mig-5 Csh Pharmaceuticals-North (Pvt) Ltd
Migzor Hilton Pharma (Pvt) Limited
Zolser Panacea Pharmaceuticals
Zomip Ferroza International Pharmaceuticals (Pvt) Ltd.
Zomoz Wilshire Laboratories (Pvt) Ltd.