zolmitriptan: clinical use

Prescribing considerations

• Confirm a clear migraine diagnosis and investigate new, atypical or focal neurological symptoms before prescribing.
• Assess cardiovascular history, blood pressure and ischaemic risk. Cardiovascular evaluation is advised where relevant risk factors are present.
• Review headache frequency and acute-treatment use because frequent use can contribute to medication-overuse headache.
• Check hepatic and renal function, age, interacting medicines and the exact product SmPC because restrictions differ between formulations.
• Review excipients: selected orodispersible products contain aspartame, while a selected film-coated product contains lactose.

Contraindications and cautions

• Hypersensitivity to zolmitriptan or product excipients
• Ischaemic heart disease, previous myocardial infarction or coronary vasospasm/Prinzmetal angina
• Previous stroke or transient ischaemic attack
• Uncontrolled hypertension; some oral products additionally contraindicate moderate or severe hypertension
• Concurrent ergot derivatives or another 5-HT1 receptor agonist
• Symptomatic Wolff-Parkinson-White syndrome or arrhythmias involving accessory conduction pathways should preclude use
• Some selected oral products additionally contraindicate peripheral vascular disease or severe renal impairment; verify the exact SmPC

Monitoring

• Assess relief of migraine symptoms, recurrence, tolerability and functional recovery.
• Monitor blood pressure where clinically appropriate and investigate persistent chest symptoms before further use.
• Observe for serotonin syndrome when serotonergic medicines are used concurrently.
• Monitor headache frequency for possible medication-overuse headache.
• Reassess cardiovascular suitability if risk factors or symptoms change.

Clinical pharmacology

Zolmitriptan is a selective 5-HT1B/1D receptor agonist acting at peripheral and central trigeminal pathways. It is metabolised partly to active N-desmethylzolmitriptan, with CYP1A2 and monoamine oxidase-A contributing to its disposition.

Formulation and product differences

• Film-coated tablets are swallowed and provide an oral formulation; the selected product contains lactose.
• Orodispersible tablets dissolve on the tongue without water but are swallowed with saliva; absorption may be delayed and products contain aspartame.
• The nasal spray is a single-use, non-oral formulation administered into one nostril. Taste disturbance and nasal discomfort or bleeding are formulation-specific effects.
• The selected nasal spray is licensed from age 12, whereas selected oral formulations are not recommended below age 18.

Nasal preparation

Route: Nasal

Strengths: 5 mg

Dispersible tablet

Route: Oral

Strengths: 2.5 mg, 5 mg

Tablet

Route: Oral

Strengths: 2.5 mg, 5 mg