Generic Name

Baqsimi

Mechanism

• Selective agonist of 5‑HT1B and 5‑HT1D receptors
• Vasoconstriction of cranial meningeal arteries → reduces neurogenic inflammation
• Inhibition of trigeminal afferent neurotransmitter release (substance P, CGRP) → dampens pain signaling
• Rapid onset (≤30 min) due to direct nasal mucosal absorption, bypassing first‑pass metabolism.

Pharmacokinetics

Indications

• Acute migraine attack (with or without aura) in adults and adolescents aged 6–17 years.
• Rapid on‑set relief preferred when oral therapy is contraindicated or poorly tolerated.

Contraindications

• Known hypersensitivity to sumatriptan, related agents, or formulation excipients.
• Uncontrolled hypertension (SBP ≥ 180 mm Hg or DBP ≥ 110 mm Hg).
• Ischemic heart disease, prior MI, or unstable angina within past 6 months.
• Significant coronary artery disease (≥ 70 % stenosis).
• Sickle cell disease or hemolytic anemia (risk of vaso‑occlusive crisis).
• Severe hepatic impairment (ALT/AST > 3× ULN).
• Concurrent use of MAO‑I, SSRIs, SNRIs, or stimulants with risk of serotonin syndrome.
• Pregnancy: Category C; use only if benefits outweigh risks.
• Breastfeeding: excreted in milk; consider risk‑benefit.

Dosing

• Adult/Adolescent (≥125 cm):
• *Initial dose*: 40 µg (one spray) per nostril at onset of attack.
• *Repeat dose*: After 2 h if pain persists, again 40 µg per nostril (max 3 doses within 24 h).
• **Younger children (6–12 yr, height 2 h between doses) without consultation.

Adverse Effects

Monitoring

• Vital signs: BP, pulse at baseline and if cardiovascular symptoms arise.
• Cardiac status: Electrocardiogram (ECG) if history of cardiovascular disease; monitor for arrhythmias.
• Serotonin syndrome signs: tremor, hyperreflexia, diarrhea, hallucinations.
• Pregnancy: Ultrasound monitoring if indicated.
• Follow‑up: Reassess pain control, tolerance of dose, and any adverse events 24 h post‑treatment.

Clinical Pearls

• Use early: Maximum benefit when administered within 1 h of attack onset; delays reduce efficacy.
• Nasal technique matters: Improper spray direction can compromise absorption; train clinicians and patients on inhalation technique.
• Combine with NSAIDs: Co‑administration can improve pain control but watch for GI side‑effects.
• Avoid excessive spacing: A 2‑hour window is standard; if symptoms recrudesce sooner, a repeat dose is acceptable, but avoid exceeding 3 doses in 24 h.
• Care with serotonergic agents: Cross‑check medication lists; consider a 3–4 day washout if co‑administered with MAO‑I, triptans, or selective serotonin reuptake inhibitors.
• Pediatric dosing accuracy: For children <125 cm, use 30 µg; over‑dosing can lead to systemic symptoms.
• Safety in cardiovascular patients: In patients with mild coronary disease, the benefit‑risk ratio should be discussed; a first dose may be administered after cardiac clearance.
• Safe storage: Keep in a cool, dry place; keep out of reach of children.
• Rapid onset allows rescue therapy to be deferred until oral agents are tolerated, which can reduce medication overuse headache risk.

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• References

(1) *Baqsimi* Prescribing Information, FDA, 2024.

(2) M. P. Roush et al., *Clinical Pharmacology of Sumatriptan Acetate Nasal Spray*, Journal of Headache Research, 2023.

(3) A. J. Smith et al., *Safety and Efficacy of Sumatriptan Nasal Spray in Children*, Neurology Pediatrics, 2022.