Can She Take Nurtec Every Other Day While Tapering Off Topamax 25 mg Every Other Day?
Yes, she can safely take Nurtec (rimegepant) 75 mg every other day while tapering off Topamax (topiramate) 25 mg every other day—there are no contraindications to concurrent use, and this combination has been studied and found to be safe.
Rationale for Concurrent Use
The FDA-approved dosing for Nurtec ODT for migraine prevention is 75 mg every other day 1. There are no drug-drug interactions between rimegepant and topiramate listed in the prescribing information 1. The primary drug interactions to avoid with Nurtec involve strong CYP3A4 inhibitors/inducers and potent P-gp inhibitors—topiramate does not fall into any of these categories 1.
Real-world evidence supports this combination. In a long-term safety study of 1,800 patients taking rimegepant, 243 (13.5%) were concurrently using preventive migraine medications, with topiramate being the most common (26.3% of those on preventives) 2. The safety profile was favorable, with adverse events comparable between those taking and not taking preventive medications (68.7% vs 59.2%) 2.
Topiramate Tapering Considerations
When discontinuing topiramate, gradual tapering is essential to minimize seizure risk. The AGA guidelines specifically state that when discontinuing phentermine-topiramate (which contains topiramate), treatment should be tapered by taking one capsule every other day for at least 1 week before stopping completely to minimize the risk of precipitating a seizure 3.
For your patient on 25 mg every other day:
- This is already a low dose and an every-other-day schedule
- Continue this regimen for at least 1-2 weeks before considering further reduction
- Could potentially reduce to 25 mg every 3-4 days for another 1-2 weeks before complete discontinuation
- Monitor for withdrawal symptoms including headache worsening, mood changes, or cognitive symptoms
Clinical Implementation
Start Nurtec immediately while continuing the topiramate taper. There is no need to wait until topiramate is fully discontinued. The patient can take:
- Nurtec 75 mg every other day for migraine prevention 1
- Topiramate 25 mg every other day (continuing current taper schedule)
- On days when both medications are due, they can be taken on the same day without concern
Monitor for:
- Topiramate withdrawal symptoms (headache increase, mood changes, cognitive changes)
- Common Nurtec side effects: nausea (most common), stomach pain, indigestion 1
- Blood pressure changes (both medications can affect BP) 3, 1
- Kidney stone risk remains elevated during topiramate taper due to its carbonic anhydrase inhibitor properties 3
Important Caveats
Topiramate is teratogenic. If the patient is of childbearing potential, ensure reliable contraception throughout the taper and discuss that topiramate can reduce oral contraceptive efficacy 4. Nurtec also requires pregnancy counseling, with a pregnancy registry available 1.
Do not rush the topiramate taper. Even at 25 mg every other day, abrupt discontinuation carries seizure risk. The slow taper recommended in guidelines (every other day dosing for at least 1 week before stopping) applies regardless of the dose 3.
Nurtec can also be used for acute migraine treatment. If breakthrough migraines occur during the taper, she can take an additional dose of Nurtec 75 mg as needed (maximum 1 dose per 24 hours), but should not exceed 18 doses in 30 days when using it for both prevention and acute treatment 1.