Zomig (Zolmitriptan) is a medication marketed by AstraZeneca and is FDA-approved as an abortive therapy for migraines and cluster headaches. Chemically, it’s classified as a triptan implying that it’s a tryptamine-derivative, and is manufactured in multiple formats including: tablet and nasal spray. Similar to other triptans, Zomig is considered efficacious when administered during a migraine attack (or upon attack onset) to attenuate the severity of symptoms.
Despite its ability to successfully abort existing migraine attacks, zolmitriptan is unable to prevent the future occurrence of migraines and therefore is not intended to be used as a prophylactic. Pharmacodynamic analyses reveal that zolmitriptan functions as a selective serotonin receptor agonist, primarily at 5-HT1B receptors (expressed within intracranial arteries) and 5-HT1D receptors (positioned upon peripheral trigeminal sensory nerve terminals). Agonism of the aforestated (5-HT1B/5-HT1D) receptors is understood to constrict intracranial blood vessels and decrease nociceptive signaling, thereby counteracting migraine.
Reports indicate that that most patients experience therapeutic migraine pain reduction within 2 hours of oral tablet administration, and in an even shorter timespan (e.g. 10 minutes) with the intranasally-administered format. Although many migraine patients respond well to zolmitriptan, a subset of individuals have a difficult time coping with its side effects. If side effects from zolmitriptan become intolerable, users may wish to pursue alternative treatments.
Zomig (Zolmitriptan) Side Effects & Adverse Reactions (List)
It is important to note that the specific side effects, total number of side effects, and severity of side effects you experience – will be subject to interindividual variation. In other words, you may experience a completely different set of side effects while taking zolmitriptan than someone else. Additionally, even if you share some side effects with another person, it is impossible to verify that the severities of these side effects are equivalent.
Despite these expected interindividual differences in zolmitriptan side effects, certain side effects are considered more common than others. The most common side effects of zolmitriptan include: chest pain, dizziness, drowsiness, dysgeusia, heaviness sensations, hot/cold flashes, pressure sensations, and tightness. Included below is a comprehensive list of all possible side effects that Zomig (zolmitriptan) users may experience following administration.
Allergic reactions: A small percentage of individuals taking Zomig ZMT may experience an allergic reaction due to the fact that the dissolvable tablets contain aspartame. Individuals diagnosed with PKU (Phenylketonuria) are very susceptible to Zomig ZMT adverse allergic reactions due to the fact that they are unable to metabolize phenylalanine, a metabolite of aspartame.
Inability to properly metabolize phenylalanine results in toxicity and a host of corresponding consequences such as: abnormal brain function, headaches, dizziness, menstrual changes, etc. Although individuals with PKU are most prone to the aspartame-related side effects (in the dissolvable tablet format), anyone could be allergic to zolmitriptan. Signs of allergic reactions to zolmitriptan could include: blurred vision, edema, skin rash, swelling, etc. If you suspect an allergic reaction, seek immediate (emergency) medical attention.
Blood pressure changes: Triptans can affect a person’s blood pressure, sometimes causing transient spikes. If you have a history of hypertension or other blood pressure abnormalities, be sure to discuss these with your doctor and confirm that zolmitriptan is not contraindicated prior to usage. Assuming it’s safe for you to take zolmitriptan, you may want to carefully monitor your blood pressure after administration to ensure that it stays within a healthy, normative range.
Some individuals have reported skyrocketing of blood pressure with each administration of zolmitriptan. In the event that you experience high blood pressure during zolmitriptan abortive therapy, you may want to reassess other options. Furthermore, beware of the long-term risks associated with high blood pressure such as arterial damage, heart attacks, and strokes.
Burning sensations: An uncomfortable, yet commonly reported side effect associated with zolmitriptan is a sensation of burning throughout the body. The burning may be isolated to one specific area of your body (e.g. head) or could occur across multiple regions. Some users mention that the burning sensation is often accompanied by feelings of “pins and needles,” tingling, tightness, or pressure.
When first using zolmitriptan, the burning sensation may be alarming and cause of significant concern. If you are worried that the burning could be harmful, contact your doctor and discuss it. For most patients, putting up with the mild-to-moderate burning sensation is a worthy sacrifice to experience relief from a migraine.
However, if the burning becomes more painful than the migraine, treatment should be reevaluated. Keep in mind that individuals administering intranasal zolmitriptan may experience some burning in the nasal passages as a result of the modality of drug delivery. In most cases, the nasal burning is transient and subsides quicker than expected.
Chest pain: Among the most common side effects resulting from zolmitriptan is chest pain. If you experience chest pain, it is important to mention it to your doctor as soon as possible. Although chest pain could be nothing more than a benign side effect, it may be a precursor sign of a more serious adverse event (e.g. myocardial infarction).
Anyone with chest pain on zolmitriptan should consult a cardiologist to rule out all potential cardiac abnormalities. The cause of chest pain among zolmitriptan users is unclear, but many speculate that it results from constriction of peripheral blood vessels. Constriction of peripheral blood vessels reduces cardiac blood flow, increases pressure, and may be the source of zolmitriptan-induced chest pain.
Cognitive impairment: During a migraine attack, it’s nearly impossible to engage in cognitively demanding tasks. This is because the throbbing head pain is at the forefront of your awareness and it’s difficult to focus on anything but the pain. Although treatment with zolmitriptan can attenuate the migraine pain, it also may significantly impair your cognitive function.
Many users have reported experiencing “brain fog” or clouded thinking within an hour of zolmitriptan administration. This inability to think clearly affects executive tasks such as: attention, critical thinking, memory, and thought speed. Reasons as to why some individuals report significant cognitive impairment from zolmitriptan remain unclear – but it may be a combination of neurophysiological factors such as: blood flow, brain waves, and neurotransmission.
Those who are most likely to notice the cognitive impairment are individuals in a cognitively-demanding occupation or academic environment. In some cases, the cognitive impairment lingers for hours after the drug has left the user’s system, while in other cases recovery is quicker. Nonetheless, if you are experiencing significant cognitive impairment each time you use zolmitriptan, you may want to talk to your doctor about adjunct strategies to mitigate this side effect (e.g. caffeine consumption) and/or alternative options.
Cold flashes: Interestingly, some people taking zolmitriptan report fluctuations in temperature resulting in sensations coldness throughout the body. Usually the cold feelings are short-lived, occurring in transient bursts or “flashes.” Some individuals notice coldness in extremities such as the hands and feet, while others may report coldness throughout the entire body.
The coldness experienced as a zolmitriptan side effect be accompanied by bouts of chills and/or shivering. Restricted peripheral blood flow to certain regions could be the reason as to why certain areas of the body feel cold after zolmitriptan administration. A majority of individuals are able to cope with medication-provoked coldness and/or cold flashes and won’t perceive them as overly bothersome.
Coordination deficits: Those taking zolmitriptan may experience temporary deficits in coordination. Coordination deficits may be especially problematic for athletes, operators of heavy machinery, and/or motor vehicle drivers. For this reason, it’s recommended to abstain from operating motor vehicles and heavy machinery while under the influence of zolmitriptan.
The exact cause of coordination deficits isn’t always clear, but it could be speculated that modulation of intracranial blood flow and/or neurotransmission play a role. It should also be noted that coordination may be impaired as a result of other common medication side effects such as drowsiness and/or somnolence – it’s difficult to maintain optimal coordination with low arousal. If you consider temporary coordination deficits to be a big deal, talk to your doctor; sometimes a simple solution such as caffeine consumption may offset some of the deficits.
Depression: A less common side effect that may occur in some zolmitriptan users is depression. The depression associated with treatment is generally mild and may result from the serotonin receptor agonism (specifically at 5-HT1B sites) elicited by the drug. It should be speculated that mood changes and/or depression are more likely to occur among zolmitriptan users with preexisting psychiatric diagnoses and comorbid migraine compared to those with sole diagnoses of migraine.
Individuals with psychiatric diagnoses may be more sensitive to neurochemical alterations, particularly within the serotonin system (known to influence mood). If zolmitriptan makes you depressed each time you use it, you may wish to consider other options. Fortunately, treatment-related depression is not usually common nor severe, usually subsiding within a day or two after administration.
Dizziness: A very common side effect of zolmitriptan is dizziness characterized as feeling faint, weak, woozy, and/or unsteady. Some have suggested that the dizziness is accompanied by balance problems, coordination deficits, and drowsiness – generating a similar feeling to drunkenness associated with alcohol intoxication. The dizziness may of moderate-to-severe intensity and can often be difficult to deal with.
Keep in mind that it’s sometimes difficult to know whether the dizziness was triggered by the migraine attack, the medication, or a combination of the two. Some zolmitriptan users find that physical activity such as walking – exacerbates their dizziness. If you become dizzy while taking zolmitriptan, your best bet may be to sit in a comfortable chair or lie down until both the migraine and dizziness diminishes.
Drowsiness: Another very common reaction to zolmitriptan is drowsiness or the combination of sleepiness and lethargy. After taking zolmitriptan, some patients may feel as if they’ve morphed into a lazy, unproductive slug with every ounce of energy depleted. Should you become drowsy, remember that it’s recommended to avoid operating heavy machinery and/or a motor vehicle – insufficient arousal makes you more prone to accidents.
Assuming you don’t want to feel drowsy while taking zolmitriptan, discuss some potentially safe adjuvant interventions with your doctor to counteract the drowsiness. A common example of an adjunct that may be recommended for certain individuals is caffeine. That said, the drowsiness is usually not long-lasting and fairly easy to manage for most users.
Dry mouth: Certain individuals may find that usage of zolmitriptan and/or other triptans provokes dry mouth (xerostomia). The neurochemical changes induced by zolmitriptan may be responsible for the dry mouth, but perhaps a more direct reaction such as swollen salivary glands is the cause. In any regard, zolmitriptan may temporarily interfere with your salivary glands’ ability to manufacture saliva, thereby causing dry mouth.
You may perceive the dryness within your mouth as a disconcerting sensation. If extreme, dry mouth can lead to halitosis (malodorous breath) due to proliferation of pathogenic bacteria. To deal with the dry mouth, consider chewing gum, make sure that you’re staying hydrated, and consider talking to a dentist.
Dysgeusia: A side effect reported in some zolmitriptan users is dysgeusia or a distorted sense of taste. You may notice a foul, metallic, or even rancid taste in your mouth that lingers for hours after taking zolmitriptan. It isn’t fully clear as to what causes the dysgeusia and why it only occurs in a limited number of individuals, however, it may be related to salivary secretion of zolmitriptan and its coming into contact with taste receptors.
In other words, after the zolmitriptan is ingested (orally or intranasally) it may end up getting released or circulated into oral cavities, ultimately interacting with taste receptor sites. Theoretically, users experiencing dysgeusia may notice concurrent ageusia (lack of taste) or hypogeusia (reduced taste sensitivity). Thankfully, the nasty taste within your mouth won’t last forever – your normative taste perception should return within a day (often much sooner).
Facial flushing: After administering zolmitriptan, some individuals may report flushing or redness of the face. This facial flushing may be related to alterations in blood flow as induced by treatment, but could also result from modification of thermoregulatory systems. It is known that zolmitriptan affects the serotonin system, and that the serotonin system affects thermoregulation.
Possible thermoregulatory alterations may change bodily temperature, leading to facial flushing and concurrent hot flashes. Most individuals with severe migraine will tolerate a bit of facial redness as long as the medication is able to abort their migraine attacks. Understand that this side effect is not unique to zolmitriptan – it is regularly reported by users of other triptans.
Fatigue: If each time you take zolmitriptan you feel as if your energy vanishes, you’re not alone. The drug is understood to reduce your arousal and cause fatigue, making it difficult to stay productive. Those that need energy for athletic, occupational, or familial endeavors may wish to discuss safe stimulatory adjuncts with a doctor to offset some of the treatment-related fatigue.
The fatigue experienced on this medication can be described as both physical and mental. You may feel as if your brain is proverbially “offline” or “shut down” (compared to pre-treatment) and as if its difficult to engage in even modest physical activity (e.g. walking). That said, the fatigue is likely to diminish after several hours and may be less debilitating among those taking lower doses of zolmitriptan.
Frequent urination: Although not mentioned as a side effect in much of the medical literature, many individuals taking zolmitriptan report frequent urination. In fact, some have experienced nocturnal enuresis (bedwetting) as a result of late-night zolmitriptan administration. Since it’s usually recommended to drink plenty of water to maintain adequate hydration during a migraine, this additional fluid consumption may also contribute to increased urinary frequency.
Most individuals can deal with the frequent urination caused by zolmitriptan, but find it annoying because they end up making trips to the bathroom every 15 minutes. If your urinary frequency is excessive and difficult to cope with, you may want to ask your doctor about a different triptan – others may not cause the same effect. On the other hand, you may be one of the lucky ones who doesn’t experience this side effect.
Headaches: Although zolmitriptan effectively treats migraines, some patients may experience non-migrainous headaches as a side effect. These headaches are significantly less severe than actual migraines and are likely caused by slightly too much vasoconstriction of intracranial blood vessels. While some vasoconstriction is needed to counterbalance the vasodilation responsible for inducing the migraine, too much vasoconstriction can cause a non-migrainous headache.
If you’re constantly experiencing headaches each time you take zolmitriptan, understand that they may result from ingesting a larger dose than was necessary to counteract vasodilation. Perhaps in this case, taking a lower dose would alleviate the milder migraine without causing a headache. That said, overuse of zolmitriptan (and other triptans) can cause “rebound headaches.”
To minimize likelihood of rebound headaches, it is necessary to stringently follow dosing and administration guidelines as outlined by a professional. Using zolmitriptan liberally and/or excessively is most likely to provoke rebound headaches. Keep in mind that while some headaches may be unavoidable as a side effect, they are typically much easier to tolerate than migraines.
Heaviness sensations: After taking zolmitriptan, you may perceive sensations of heaviness in various parts of your body such as the head, neck, jaw, etc. Some individuals may experience heaviness sensations within their arms and legs, making it difficult to engage in any sort of physical activity while medicated. The heaviness may be accompanied by increased pressure and/or weakness, and is theorized to result from constriction of peripheral blood vessels.
For most, the heaviness sensations are isolated to a particular area of the body and are regarded as an expected, yet odd side effect of zolmitriptan. The intensity of bodily heaviness tends to diminish within several hours of treatment and is usually manageable. Many users find it helpful to lie down and/or refrain from rigorous physical activity until the heaviness abates.
Hot flashes: As was already noted, cold flashes often occur during treatment with zolmitriptan – but so do hot flashes. Hot flashes are characterized as sudden bursts of feverish heat, sometimes accompanied by facial redness or flushing. It is plausible that hot flashes may result from zolmitriptan’s modulation of serotonergic transmission.
Serotonergic abnormalities are highly linked to alterations in thermoregulation, which can promote hot flashes; hence reason as to why they may occur during treatment. It could also be that hot flashes manifest from changes in cerebral blood flow. Regardless of the specific means by which zolmitriptan induces hot flashes, most users realize that they are a small toll to pay for migraine relief.
Irregular heartbeat: You may notice that your heartbeat feels abnormal or starts to flutter after taking zolmitriptan. The change in your heart rhythm may be nothing more than palpitations that could be exacerbated by anxiety. That said, it is important to avoid automatically assuming that the heart rhythm irregularities are a benign side effect – they could be the sign of a more serious adverse cardiac event (e.g. heart attack).
If you’re experiencing an irregular heartbeat during zolmitriptan treatment, it is necessary to consult a cardiologist for a thorough cardiac evaluation. It is known that zolmitriptan (and other triptans) can restrict cardiac blood flow, possibly leading to heartbeat irregularities and/or chest pain. Those at risk for cardiac abnormalities should be carefully monitored during treatment and contraindications should be assessed.
Jaw pain: Some users of zolmitriptan will experience jaw pain and pressure as a side effect. The jaw pain may be mild for some, but severe for others – possibly to the extent that it’s difficult to chew or consume food. Usually the jaw pain becomes most severe within the first several hours after administration and tends to dwindle thereafter.
The pain within your jaw region could be related to the vasoconstrictive effect of the medication. While experiencing this jaw pain, you may want to refrain from eating any difficult-to-chew foods. Consider that gently massaging the area with your hands may help reduce some of the pain and understand that it will likely subside quicker than expected.
Lightheadedness: Migraine patients commonly experience lightheadedness during the onset of a migraine attack, but also after administering an abortive medication like zolmitriptan. Treatment with zolmitriptan may provoke lightheadedness by constricting intracranial blood vessels and reducing blood flow. The lightheadedness could also be triggered by modifications in neurotransmission of serotonin.
If you’re feeling lightheaded, you may want to consider resting and/or lying down. Sometimes the lightheadedness may worsen if you force yourself to remain physically active. As the blood flow stabilizes, severity of your migraine reduces, and the medication exists systemic circulation – the lightheadedness tends to fade.
Muscle pain: The term myalgia is defined as pain in a muscle or group of muscles – and is sometimes reported as a side effect of zolmitriptan. Myalgia triggered as a side effect is described as achiness that may be accompanied by physical weakness. Though the aches and pains throughout muscles are certainly unwanted, sometimes they cannot be avoided.
For most users experiencing muscle aches as a side effect, it may be necessary to simply “suck it up” and fight through them. That said, if you find that the myalgia is unbearable, be sure to discuss it with your doctor. When compared to the initial pain of a severe migraine, muscular aches and pains from zolmitriptan are generally minor.
Nausea: Although it is common for migraine patients to report emetic symptoms such as nausea and vomiting during an attack, these symptoms may also occur as a side effect of an abortive medication. In some cases, zolmitriptan users such extreme nausea that it provokes vomiting. If each time you take zolmitriptan you feel highly nauseous, inform your doctor of this reaction.
There may be alternative medications to zolmitriptan to consider that wouldn’t cause you to feel so nauseous. Additionally, your doctor may even prescribe an adjunct antiemetic [possibly with antimigraine properties] to help you cope (e.g. Reglan for migraines). Some ways to cope with medication-induced nausea include: taking zolmitriptan after a meal, staying hydrated, and lying down (to minimize dizziness).
Neck pain: As was already mentioned, aches and pains may occur throughout your muscles (myalgia) from zolmitriptan treatment. That said, many users experience noticeable pain specifically localized within the neck region after zolmitriptan takes full effect (within 1-2 hours). The neck pain may be accompanied by significant pressure and could be a result of blood flow alterations (related to vasoconstrictive effects elicited by zolmitriptan).
Some individuals with neck pain may also notice that the outside of their throat hurts as well – making it difficult to swallow. If you experience neck pain or tenderness, it may help to lie down on a soft, comfortable pillow until the pain subsides. It may also help to gently massage the neck or specific areas of the neck that are in the most pain.
Numbness: A relatively common side effect of zolmitriptan is the sensation of numbness. Medically, the numbness resulting from zolmitriptan is referred to as hypesthesia, a term signifying the diminished capacity for physical sensation on the skin. Some may feel as if they’ve been injected with a variation of procaine (often referred to as “Novocain”) and as though perception of tactile stimuli is altered due to the drug-induced numbing.
It should be noted that some users may report numbness localized within one specific area or region, whereas others will notice it throughout the entire body. Since it is understood that zolmitriptan exerts a peripheral vasoconstrictive effect, this effect may help explain sensations of numbness. Vasoconstriction reduces blood flow to an area (or areas), which could theoretically create a feeling of numbness – as well as “pins and needles” (also commonly reported).
Sensory hypersensitivity: Some individuals may notice that they become hypersensitive to sights, sounds, smells, tastes, and/or tactile sensations – during treatment with zolmitriptan. Although sensory hypersensitivity can occur as a result of medication, it can also be triggered by the migraine itself. This makes it difficult for patients to know whether their sensitivity to sounds or sights was caused by the drug, the migraine, or a combination of both.
That said, most patients know whether they experienced hypersensitivity of senses prior to treatment, and will have a good idea as to whether senses have become increasingly sensitive as a result of medication. If the sensory hypersensitivity is amplified to such a significant extent that it impairs your ability to function, talk to your doctor about other pharmaceutical options. Depending on the specific type of sensory hypersensitivity that you’re dealing with, there may be helpful mitigation strategies (e.g. sunglasses for bright lights).
Sleepiness: Don’t be surprised if after taking zolmitriptan, you end up drifting off to sleep. Sometimes the side effect of sleepiness is preferred by migraine patients while recovering from an attack because they aren’t as conscious of the pain and/or side effects of the abortive therapy during slumber. That said, since migraine attacks are usually unpredictable and may occur at an inopportune time for sleep (e.g. during work), sleepiness is not always perceived as a favorable side effect.
Those who need to maintain vigilance after zolmitriptan takes effect may want to consider utilizing a stimulatory adjunct (e.g. caffeine). In other cases, you could talk to your doctor about trying a lower dose to determine whether a reduced quantity of the drug is able to ameliorate the migraine attack, without making you sleepy. If you feel sleepy each time you use zolmitriptan, it is necessary to refrain from operating motor vehicles and/or heavy machinery.
Sore throat: A subset of individuals taking zolmitriptan tend to experience soreness of the throat. There are numerous possible reasons as to why a sore throat may occur as a side effect of abortive therapy. The sore throat may be a result of excessive vasoconstriction in this particular area, thus reducing blood flow and increasing pressure – possibly making it difficult to swallow or even speak.
Some patients may also develop a sore throat from administering the intranasal spray format of zolmitriptan. When administered intranasally, the medication sometimes drips back down within the throat area and could cause soreness (along with taste abnormalities). Fortunately, the sore throat as a side effect won’t be as severe as a condition like Strep Throat (i.e. Streptococcal pharyngitis) and often diminishes within hours.
Sweating: It is possible that you may find yourself sweating a bit more than usual within several hours following zolmitriptan administration. The increase in perspiration may be mild to the extent that your skin feels a bit slimier than usual – or perhaps more extreme to the extent that you’re soaking clothing, bed sheets, etc. in your sweat. The sweating could be caused by an interaction between zolmitriptan and the sweat glands.
On the other hand, it could be part of a cascade reaction in which: the serotonergic modulation (elicited by zolmitriptan) alters thermoregulation, changes your body temperature, and perspiration occurs as a response to normalize temperature. Luckily, other than possibly needing a shower and change of clothes, sweating isn’t perceived as problematic. That said, if you sweat a lot, be sure to compensate by drinking more water and consuming electrolytes (sodium, potassium, magnesium, etc.).
Tightness: Some migraine patients may experience tightness throughout the body as a result of zolmitriptan. The tightness could be caused by modulation of peripheral blood flow and constriction of blood vessels. The tightness experienced may be most noticeable within a specific region such as the jaw, throat, chest, or neck – but could also occur throughout multiple regions simultaneously.
There doesn’t appear to be a way to offset this tightness. Cutting back on the dosage administered may be useful, but then the efficacy of zolmitriptan may be reduced. It may help to massage the tight areas in effort to enhance circulation. That said, sometimes it’s best to realize that a temporary bout of tightness or tension may be an inevitable side effect of treatment.
Tingling sensation: All triptans tend to carry the side effect of paresthesia or the abnormal sensation of tingling/prickling across the skin. Paresthesia is perhaps most accurately explained as a feeling of “pins and needles,” and may be caused by blood vessel constriction. Constricted peripheral blood vessels tends to reduce blood flow in certain regions, possibly leading to unexpected tingles and/or numbness.
Sensations of tingling may also be caused by increased pressure upon peripheral nerves and/or nociceptive processes as induced by medication. Despite the fact the tingling certainly feels odd and abnormal, it tends to subside within hours after initially becoming noticeable. It is unclear as to whether anything can be done to reduce the minor annoyance of these skin tingles.
Vertigo: If each time you take zolmitriptan you experience a sensation that objects around you are moving and feel unbalanced – you may be dealing with vertigo as a side effect. Vertigo is usually associated with inner ear disorders, but can sometimes occur as a reaction to medication. It may be caused by altered blood flow, nerve functionality, neurochemical adjustments, and vasoconstriction – which throw off a user’s equilibrium.
If you happen to be among the subset of individuals that is plagued by vertigo as a side effect, you may want to take it easy and rest until it abates. Some have found massages to be helpful and soothing while experiencing vertigo. A lower dose of medication, adjunct treatment, or possible medication change should be considered if vertigo is substantial.
Weakness: It’s no secret that some individuals experience asthenia or extreme physical weakness after taking zolmitriptan. The weakness may be a byproduct of peripheral vasoconstriction and reduced blood flow to certain areas of the body. It may also be a result of various reactions to the medication such as dizziness, fatigue, sleepiness, etc. – after all, it’s difficult to feel strong when plagued with these side effects.
Since you may feel weak from zolmitriptan treatment, you probably won’t want to lift heavy weights or force yourself to engage in strenuous exercise until your strength returns. Physical strength should fully return in less than 24 hours following administration. If you’re feeling weak from treatment, focus on rest, relaxation, and recovery.
Note: If you have questions about any of the above-listed side effects, be sure to consult a medical professional.
Variables that influence Zomig (Zolmitriptan) side effects
When contemplating the side effects that you’re likely to experience from zolmitriptan, it is necessary to account for variables most likely to influence side effect severity and occurrence. These variables are useful in that they may help explain why one user experiences completely different and/or more prominent side effects than another. The most critical variables in regards to influencing side effects include: zolmitriptan dosage, co-administered substances, frequency/term of administration, modality of administration, and specific individual factors.
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Dosage (High vs. Low)
The dosage of zolmitriptan you administer can significantly influence the severity of side effects that you experience. As a general rule of thumb, the higher the dosage of zolmitriptan you ingest, the more likely you are to experience side effects. Oppositely, the lower the dosage of zolmitriptan you require for migraine relief, the less likely you are to experience side effects.
Side effects tend to be more prevalent at higher doses because an increased amount of the drug necessitates metabolism, undergoes circulation, and exerts an effect upon neurophysiology. Since we know zolmitriptan functions as a serotonin receptor agonist, we can expect more potent receptor agonism at a high dose (e.g. 5 mg) compared to a lower one (1.25 mg). More substantial agonism triggers greater vasoconstriction and likely more noticeable side effects.
Additionally, high dosages shift neurophysiology to a larger degree away from homeostasis, leading to various internal mechanisms that attempt to make corrections and restore homeostatic function. These endogenous compensatory mechanisms responsible for homeostatic maintenance may also give rise to more side effects among high-dose users. On the other hand, someone taking a low dose will be less likely to experience side effects.
This is because lower doses are generally easier to metabolize, form fewer metabolites, exert less of a neurophysiological effect – and ultimately less vasoconstriction. Furthermore, the endogenous in-built mechanisms won’t need to work as hard to restore homeostatic processes during treatment among lower dose users. In summary, the greater the dose taken – the more likely side effects are to occur, and the greater severity they are likely to be.
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Co-administered substances
Concurrent or adjunct administration of various drugs and/or supplements can influence the side effects experienced from zolmitriptan. Co-administered substances could significantly affect the pharmacokinetics of zolmitriptan, as well as facilitate the amplification or attenuation of its pharmacodynamics – possibly to the extent of contraindication. Additionally, other substances that may not affect its pharmacokinetics or interact with its pharmacodynamics could still serve to inhibit or exacerbate various side effects.
Medical literature indicates that taking zolmitriptan within 2 weeks of using an MAOI or 24 hours of administering: 5-HT1 agonists, ergotamine-containing medications, ergot-type drugs, or methysergide – is contraindicated. Taking zolmitriptan with any of the aforestated drugs could lead to severe adverse reactions. To rule out contraindications, be sure to tell your doctor of all drugs and supplements that you’re using while taking zolmitriptan.
Since it is understood that zolmitriptan is primarily metabolized via the CYP1A2 pathway, we can speculate that any agents modulating this pathway may increase (or decrease) its side effects and overall efficacy. For example, CYP1A2 inducers are be thought to expedite the metabolism of zolmitriptan, possibly leading to fewer side effects. Examples of some CYP1A2 inducers include: foods (broccoli, Brussels sprouts, cauliflower), modafinil, omeprazole, and tobacco.
Conversely, administration of drugs that inhibit the CYP1A2 metabolism of zolmitriptan may provoke more side effects due to prolonged metabolism and systemic circulation. Examples of some common CYP1A2 inhibitors include: ciprofloxacin, fluvoxamine, St. John’s wort, and verapamil. Understand that pharmacokinetic interactions stemming from another substance’s CYP1A2 modulation apply less to those using the Zomig nasal spray (as its pharmacokinetics slightly differ from those of oral formats).
Additionally, the degree to which CYP1A2 inhibitors and inducers influence side effects of zolmitriptan may be contingent upon their respective dosages. Other substances may interact with zolmitriptan pharmacodynamically (via simultaneous modulation of serotonin systems). Moreover, some substances may not interact with zolmitriptan at all, but could effectively offset or blunt certain side effects (e.g. caffeine may decrease zolmitriptan-induced drowsiness).
It is also necessary to emphasize that certain individuals could mistakenly attribute side effects they experience to zolmitriptan, when they were really caused by another simultaneously administered substance. Attribution of another drug’s side effect to zolmitriptan may be most common among those who introduce multiple new treatments simultaneously. For this reason, it may be helpful to work with your doctor to distinguish whether the unwanted side effects you’re experiencing are 100% from the zolmitriptan OR more so from another agent (medication or supplement).
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Frequency of Use (High vs. Low)
The frequency at which you use zolmitriptan can influence side effects that you experience. As a hypothetical example, someone taking zolmitriptan 5 times per week may experience more profound side effects than if the same individual were to administer the drug at a frequency of just 1 time per week. In this case, the side effects may be more severe and/or numerous as a result of highly-frequent usage due to greater disruption of homeostasis over the course of the week.
In cases of highly-frequent administration and/or overuse of zolmitriptan (and other triptans), medical literature suggests that users are more prone to rebound headaches. It is important to consider that frequent usage may also increase likelihood and/or severity of other between-dose side effects. Based on this information, it is obvious that some high-frequency users could experience some side effects that lower-frequency users won’t experience.
Conversely, it may be that lower-frequency users could experience some side effects that high-frequency users wouldn’t experience. This may be due to the fact that when administered at a lower frequency, the body isn’t expecting to receive the drug, so when ingested – it has a greater impact on neurophysiological processes. A higher-frequency user’s body may have learned to expect and accommodate for the presence of zolmitriptan, thereby reducing likelihood of certain compensatory reactions that trigger side effects.
Keep in mind that there’s usually not a clear-cut, universally predictable relationship between frequency of administration and side effects. You may notice that infrequent usage yields fewer side effects, whereas another individual may experience less severe side effects when administered with greater regularity. Additionally, it is important to consider that frequency may indirectly affect the dosage of zolmitriptan that is administered – a variable that has the most profound influence on side effects.
For example, a high frequency user could theoretically build up a slight tolerance to the effects of zolmitriptan at a low dose (e.g. 1.25 mg). As a result of the highly frequent administration, the user may find that the dose stops working as well as it initially did, and consults his/her doctor for advice. The doctor may recommend bumping up the dose to 2.5 mg, which may work better for the migraines, but also trigger more side effects (due to increased effect exerted upon the user’s neurophysiology).
A lower dose user may never build up any sort of tolerance to the drug and may find that a really low dose (e.g. 1.25 mg) works well. Since less drug is circulating throughout the low dose user’s system, he/she won’t be as prone to side effects. In summary, when assessing the side effects that you’re experiencing from zolmitriptan, consider that the frequency of administration may play an important role.
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Modality of Administration
Zolmitriptan is manufactured in several formats including: standard tablet, orally-disintegrating tablet, and intranasal spray. Though all formats are regarded as clinically effective and approved by the FDA to abort migraine attacks, the modality of administration may influence the side effects that you experience. Certain individuals may find that they’re able to tolerate one zolmitriptan format better than other.
For example, one user may find the ODT format more tolerable than the nasal spray, while another user may have the exact opposite experience. Although the medical literature indicates that all formats are equally well-tolerated, this doesn’t automatically rule out the fact that there may be interindividual differences in format-specific side effects. To rule out format-specific side effects, it may be helpful to test all three formats and determine which provokes the fewest adverse effects.
Tablet (Standard): Standard zolmitriptan tablets are manufactured in 2.5 mg and 5 mg doses and administered orally. They undergo first-pass hepatic metabolism facilitated primarily by CYP1A2 isoenzymes. Additionally, there will be interindividual variation in how quickly zolmitriptan tablets are metabolized based on expression of the CYP1A2 gene; polymorphisms may result in expedited metabolism for some and poor metabolism for others.
There isn’t much difference between the conventional zolmitriptan tablets and the orally-disintegrating tablets – other than the fact that the conventional tablets are devoid of aspartame. Assuming you react poorly to aspartame, you may experience fewer side effects with the standard tablets by comparison. Furthermore, modest differences in pharmacokinetics may be apparent due to the fact that standard tablets are ingested altogether, whereas the disintegrating tablet may break down gradually in the mouth – ultimately entering systemic circulation at a slightly different rate.
Since standard tablets are not dissolving in your mouth (like the ODT format) nor sprayed up your nostrils (like the nasal spray format), you may evade irritation within the throat and nasal passages – that may occur with each of the other formats, respectively. However, you may be most at risk for pharmacokinetic interactions due to the first-pass effect. Moreover, a greater amount of the N-desmethyl-zolmitriptan metabolite will form quicker, agonizing serotonin receptors more significantly in less time than the nasal format – possibly generating more side effects.
Orally disintegrating tablet (ODT): Zomig ZMT is sold as a novel, orally-disintegrating tablet – making it very simple to administer. Rather than swallowing zolmitriptan with a glass of water, all patients need to do is place the Zomig ZMT on their tongue and it dissolves. As was already discussed, the pharmacokinetics of Zomig ZMT differ ever-so-slightly from standard zolmitriptan tablets in that the the standard tablets do not dissolve on the tongue and are swallowed altogether.
For all intents and purposes, most would consider the pharmacokinetics of the standard and ODT formats identical. Perhaps the most important difference between the two formats is the inclusion of aspartame within the ODT format. Aspartame is contraindicated among a subset of individuals (e.g. those with PKU), but may provoke side effects in the general population with an aspartame sensitivity.
Like the standard zolmitriptan tablets, Zomig ZMT undergoes first-pass hepatic metabolism facilitated by CYP1A2 isoenzymes. This means that users of the ODT version may be more susceptible to pharmacokinetic interactions than those administering intranasal formats. Formation of the N-desmethyl-zolmitriptan metabolite occurs quicker among those taking the ODT version than the intranasal formats, which may result in more pharmacodynamic-related side effects.
Theoretically, it could also be thought that an orally disintegrating zolmitriptan may irritate the throat and/or increase likelihood of taste-related side effects due to the fact that it dissolves in the mouth. Whether adverse events are more likely to occur within the mouth and/or throat resulting from oral zolmitriptan (compared to the standard oral format) remains unclear. That said, an orally disintegrating zolmitriptan shouldn’t irritate the nasal passages (as may occur with the nasal spray format).
Nasal spray: The format of zolmitriptan intranasal spray is manufactured in packages of single-use sprays. Medical documentation suggests that the starting dose for those using the intranasal zolmitriptan is 2.5 mg – with repetition once in 2 hours if migraine is still unresolved. The maximum recommended single dose of the nasal spray is 5 mg, and maximum daily dose is 10 mg (within 24 hours).
Studies indicate that intranasal zolmitriptan is absorbed quicker than when administered orally (in conventional or disintegrating tablet). Intranasally administered zolmitriptan becomes detectable within plasma in less than 2 minutes. However, the appearance of zolmitriptan’s chief pharmacologically active metabolite (N-desmethyl-zolmitriptan) is delayed when administered intranasally (compared to oral formats).
This delay in appearance of N-desmethyl-zolmitriptan metabolites is thought to provide a longer window of antimigraine effect. The delay in N-demethylation (to form the N-desmethyl metabolite) is due to the fact that intranasal formats are not subject to first-pass metabolism. Based on the lack of a first-pass metabolism, we know that pharmacokinetic-related side effects and/or interactions are less likely to occur.
Administration of intranasal zolmitriptan increases likelihood of nasopharyngeal adverse effects compared to oral tablet formats. Approximately 5.5% of all intranasal spray users (at 5 mg) will experience nasopharyngeal adverse effects. That said, it should be expected that an intranasal spray could cause burning, irritation, numbness, etc. – within the nasal passages and the throat.
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Genetics (CYP1A2)
Your gene expression may influence how well you tolerate zolmitriptan, particularly the orally-administered formats. Evidence suggests that zolmitriptan is metabolized hepatically, primarily by the isoenzyme CYP1A2. CYP1A2 converts the parent drug (zolmitriptan) via N-demethylation to form the active metabolite N-desmethyl-zolmitriptan. This metabolite exerts an effect upon serotonin receptors between 2-fold and 8-fold greater than its parent – meaning it is of greater potency.
In any regard, since expression of CYP1A2 isoenzymes can differ as a result of a user’s genetics, genes must be considered to influence side effects (and efficacy) of zolmitriptan. Polymorphisms of CYP1A2 can alter the absorption, metabolism, and systemic clearance of zolmitriptan and its metabolites, thereby increasing or decreasing likelihood of certain side effects. Several possible CYP1A2 expressions are discussed below in respect to zolmitriptan side effects.
- Ultrarapid metabolizers: A small percentage of the population is thought to metabolize zolmitriptan much quicker than usual and are referred to as ultrarapid metabolizers. If you are an ultrarapid metabolizer, you’ll have one or more alleles that enhance enzymatic activity of CYP1A2 compared to extensive metabolizers. This results in a faster onset of the active metabolite’s action. However, due to the fact metabolites form so quickly in ultrarapid metabolizers, side effects should be more pronounced – but not as long-lasting.
- Extensive metabolizers: Most of the population falls under the classification of extensive metabolizers. This indicates that they have 2 normally functioning CYP1A2 alleles and will metabolize zolmitriptan at a normal rate, as well as eliminate it from systemic circulation in a predictable timespan. Among these individuals, zolmitriptan should be effective – and the occurrence/severity of side effects should be considered normal.
- Intermediate metabolizers: These are individuals that have one normatively functional CYP1A2 allele and another deemed non-functional. As a result, they are able to metabolize zolmitriptan, but less efficiently than most of the population. The less efficient metabolism may result in slower onset of drug action and may increase susceptibility to certain side effects – especially among those taking the oral versions of zolmitriptan.
- Poor metabolizers: Some individuals may possess multiple non-functional alleles, resulting in diminished or nonexistent CYP1A2 activity. While it is rare to be classified as a poor CYP1A2 metabolizer, this variation has been discovered in a small percentage of people. One study found that Ethiopians are more at risk for insufficient CYP1A2 activity than other ethnicities. If you’re a person with poor CYP1A2 metabolism: the drug will be metabolized less efficiently, plasma concentrations of the parent chemical (zolmitriptan) will remain elevated, and side effects may occur for longer duration than in an extensive metabolizer.
To determine the rate at which you metabolize zolmitriptan, you may want to consider genetic testing via services like GeneSight. Also, you may want to consider that if you are an extensive metabolizer, but co-administer an inducer or inhibitor of CYP1A2 – your metabolism of zolmitriptan may appear closer to that of an ultrarapid or intermediate metabolizer. Interestingly, CYP1A2 tends to be greater among males than females AND among smokers compared to non-smokers.
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Individual factors
Assuming two individuals administered standalone zolmitriptan at the same frequency, format, and dosage – plus exhibited the same genetic CYP1A2 expression – side effects could still significantly differ among the users. One may complain of significant dizziness and nausea, while the other may not experience dizziness nor nausea, but may instead complain of heart palpitations and balance problems.
What explains the differences in side effects between these two (hypothetical) individuals? Specific individual factors. These factors are things like: administration specifics, body size, genetics/epigenetics, comorbid medical conditions (besides migraine), sex, sleep (quality/quantity), and stress level.
- Administration specifics: Administration specifics refer to the timing of zolmitriptan ingestion (morning, afternoon, evening), whether it was taken with or without food, how hydrated the person is, etc. A person taking zolmitriptan in the morning may experience different side effects than had that same person took it in the evening. This is because the biological processes occurring within the body differ in the morning from the evening based on internal circadian rhythms. As a result of circadian rhythms, side effects may be more or less noticeable at certain times of the day. Additionally, whether zolmitriptan was taken with food or on an empty stomach could increase (or decrease) susceptibility to side effects – depending on the person. Food (or lack thereof) may slightly alter speed of absorption, as could the type of food (carbs, proteins, fats) – thereby yielding slightly different side effects.
- Body size: A person’s body size may have a slight influence on side effects as well. A larger person may metabolize and excrete a 5 mg dose of zolmitriptan at a different rate than a smaller individual. This is partly why most medications are prescribed at lower dosages to children than adults. Moreover, a person’s body composition such as muscle mass and/or body fat percentage – could also play a role in drug excretion and thus influence certain side effects.
- Genetics / Epigenetics: As was already discussed, genes encoding for CYP1A2 isoenzymes will affect the pharmacokinetics of zolmitriptan, making some people more prone to side effects. It should be speculated that other (non-CYP1A2) genes may also predict how well the drug is tolerated. Furthermore, since we know epigenetic expression can also affect neurophysiology, epigenetics must be considered as playing a role, even if unmeasurable, in zolmitriptan tolerability.
- Hepatic impairment: Those with moderate to severe hepatic impairment are understood to metabolize the drug less efficiently than those with healthy liver function. For this reason, it should be expected that side effects will be more pronounced at lower dosages among those with hepatic impairment. In other words, the more severe the impairment, the less of the drug a patient can safely handle for metabolism and the more susceptible he/she will be to side effects.
- Medical conditions: Those taking zolmitriptan for migraines may suffer from other medical conditions that influence how they’ll respond to abortive treatment. As was already discussed, those with PKU cannot take the orally-disintegrating format of zolmitriptan due to the fact that the aspartame contents will trigger adverse events. Manufacturer documentation indicates that zolmitriptan is contraindicated among those with conditions such as: blood circulation problems, cardiac abnormalities, hypertension, a history of stroke, and many more. Keep in mind that even those with conditions in which zolmitriptan is not contraindicated, the condition may increase susceptibility to adverse effects.
- Sleep / Stress: The quality and quantity of sleep that a person regularly gets may affect how they respond to zolmitriptan. Someone who doesn’t get much sleep will exhibit different hormone and neurotransmitter concentrations than someone who’s well-rested. The person who regularly gets enough sleep may perceive side effects of zolmitriptan as being less debilitating than someone who fails to get adequate sleep. Furthermore, it is plausible that a sleep deprived individual may have a difficult time distinguishing certain side effects from effects of sleep deprivation – leading them to mistakenly assume that the drug is causing everything (or vice-versa). Stress can have a similar impact – those who are overly stressed may end up experiencing side effects that wouldn’t have occurred had they been relaxed.
Zomig (Zolmitriptan): Do the benefits outweigh the side effects?
Whenever taking an abortive therapy for migraine such as zolmitriptan, it is important to assess whether the therapeutic benefits outweigh its side effects. In a utopian scenario, a patient would take zolmitriptan and experience migraine relief without any noticeable side effects. Believe it or not, some patients report no side effects from treatment and find that zolmitriptan significantly attenuates the severity of migraine attacks.
In a dystopian scenario, zolmitriptan would be ineffective for the treatment of migraines and would provoke deleterious and/or unwanted side effects. Assuming a person has tested zolmitriptan and finds that it is completely useless for the treatment of their specific type of migraine and/or is incompatible with their neurophysiology – discontinuation is likely the only logical choice. However, a bulk of zolmitriptan users will not experience the utopian (all benefit / no drawbacks) nor the dystopian (no benefit / all drawbacks) scenarios.
Most migraine patients will report experiencing a mix of benefits and side effects – usually with a therapeutic benefit overshadowing some minor side effects. If you experience a few unwanted side effects each time you take zolmitriptan (e.g. dizziness, nausea, somnolence), yet the severity of your migraine dramatically improves within 1 hour – you’ll likely be willing to continue treatment. Some side effects are to be expected with most pharmaceutical interventions, especially triptans, but most are of modest concern.
On the other hand, if you derive benefit from zolmitriptan, but experience spikes in blood pressure or end up vomiting after each administration – it may be necessary to cease usage in favor of an alternative medication or therapy. The goal of zolmitriptan treatment is to abort a migraine, but the debilitation resulting from side effects should be less significant than that of the actual migraine. Understand that it is ultimately a personal decision as to whether you’d like to continue zolmitriptan treatment.
If you’re new to treatment with this drug, you may want to maintain a journal to track its efficacy over time – as well as side effects you experience. By documenting degree of efficacy (e.g. how quickly it works, significance of migraine-related pain reduction, etc.) and side effects over time in a journal, you’ll be able to convey this information to your doctor. This personal data tracking will help you and your doctor make the decision as to whether you should stay the course or test another medication.
Possible ways to reduce Zomig (Zolmitriptan) side effects
If you’re experiencing side effects as a result of zolmitriptan, it may be helpful to consider possible side effect mitigation strategies. Prior to implementing any of these strategies, it is critical to confirm safety and speculated efficacy of each based on your individual medical status. Some ways by which users may be able to reduce zolmitriptan side effects include: dosage reduction, format switch,
- Dosage reduction: Perhaps the easiest way to reduce side effects as a result of any abortive therapy is to ensure that you’re taking the minimal effective dose. In other words, it may be helpful to start with an extremely low dose of zolmitriptan and gradually titrate your way up until you’re taking the least possible dosage to abort the migraine attack. By taking the lowest possible dose (and nothing more), you may minimize the severity and/or number of side effects that you’d experience from a higher dose.
- Format switch: There are three distinct formats of zolmitriptan engineered for the treatment of migraines including: oral tablet, orally disintegrating tablet, and nasal spray. As was explained above, someone may tolerate the nasal spray better than either of the tablets, whereas another migraine patient may tolerate one of the tablets better than the spray. If you’re experiencing side effects from the current format of zolmitriptan that you’re taking, and you or your doctor suspect that some of the bothersome side effects may be format-specific (e.g. burning in nostrils after spray) – you could consider changing formats in hopes of fewer side effects.
- Adjunct substances: There may be times in which patients may be able to safely administer an adjunct along with zolmitriptan to attenuate its side effects and/or enhance its antimigraine effect. For example, if you experience severe brain fog, fatigue, and cognitive deficits each time you take zolmitriptan – but need to maintain alertness for work, your doctor may be able to recommend a safe adjunct drug or supplement that offsets the low energy and cognitive impairment. The specific adjuncts recommended to be taken with zolmitriptan will be contingent upon safety, as well as the patient-specific side effects.
- Discontinue other substances: If you’re experiencing severe side effects from zolmitriptan, it may be necessary to evaluate the other drugs and/or supplements that you’re using and evaluate whether they may interact with zolmitriptan. Although your doctor should rule out any contraindications prior to treatment, it is the onus of the patient to keep the doctor informed about other substances they regularly use. Assuming none of the other substances you use are medically necessary, discontinuation may reduce the side effect burden of zolmitriptan. Agents that modulate CYP1A2 (via induction or inhibition) should be considered.
- Take with food: Although you cannot control the time of day at which you administer zolmitriptan (as migraines cannot be scheduled), you can decide whether you take it along with food or on an empty stomach. If you are tolerating the oral formats poorly on an empty stomach, it may be wise to consider eating some food around the time of administration to determine whether certain side effects (e.g. nausea) improve. Conversely, if you feel awful after taking zolmitriptan on a full stomach, you may want to try taking it without food and assess whether side effects improve. (Keep in mind that cruciferous veggies [and select other foods] modulate CYP1A2 function and should likely be avoided around time of administration).
- Continue using: If you just began using zolmitriptan for migraines and are experiencing some unwanted side effects, you may want to test it a few more times before concluding that it’s intolerable. In a subset of users, side effects may diminish with each successive administration. Usually after a month or so you’ll have an accurate idea as to whether zolmitriptan is becoming more tolerable than when you first started treatment.
Have you experienced Zomig (Zolmitriptan) side effects?
If you’ve used (or are currently using) zolmitriptan for migraines, mention whether you’ve experienced any side effects or adverse reactions in the comments section below. Assuming you have dealt with some side effects from zolmitriptan, mention which specific side effects are most debilitating and how long they last after administration. Also mention the dosage plus format of zolmitriptan you take, and whether you’ve found it to be more tolerable than other dosages and/or formats.
To help others get a better understanding of your situation, include some details in your comment such as: concurrent medical conditions (besides migraines), usage of other substances (medications, supplements, etc.), CYP1A2 expression (if you’re aware of it), and type of migraine you experience. In your personal experience, would you say that the therapeutic efficacy of zolmitriptan outweighs the side effects? Or do you anecdotally believe that the deleterious side effects of zolmitriptan surpass its therapeutic benefit?
If you know of any additional ways to mitigate and/or cope with side effects of zolmitriptan (other than the methods outlined above), feel free to share. Understand that no medication for the treatment of migraines will be optimal for everyone; some will tolerate zolmitriptan well, while others won’t. Work with a medical professional to discuss side effects and determine whether zolmitriptan is right for you.