From the Guidelines
For a patient with worsening migraines on nightly Topamax, I recommend adding a gepant like Nurtec (rimegepant) or Ubrelvy (ubrogepant) as an acute treatment medication, rather than a triptan, due to their favorable safety profile and efficacy in treating moderate to severe acute episodic migraine headache. According to the most recent guideline from the American College of Physicians 1, gepants are a recommended option for treating moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen.
The choice between Nurtec (75mg) and Ubrelvy (50-100mg) depends on individual factors, such as the frequency of migraine attacks and the patient's medical history. Gepants have fewer cardiovascular restrictions compared to triptans and may cause less rebound headaches, but are more expensive. It's essential to consider the patient's preferences, cost, and potential side effects when making this decision.
While triptans like sumatriptan (25-100mg) or rizatriptan (5-10mg) are also effective in treating migraines, they should be limited to 2-3 days per week to avoid medication overuse headache and are contraindicated in patients with cardiovascular disease. The 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache also suggests rimegepant or ubrogepant for the short-term treatment of migraine 1.
In addition to adding an acute treatment medication, it's crucial to continue the preventive Topamax and consider reassessing its dosage (typically 50-200mg daily) if migraines remain poorly controlled. The combination approach targets both prevention and acute treatment through different mechanisms, with Topamax reducing neuronal hyperexcitability and acute medications blocking pain pathways during attacks.
Key considerations when adding a gepant or triptan to Topamax include:
- Monitoring for potential side effects and interactions
- Educating the patient on the proper use of acute treatment medications and the importance of not overusing them
- Regularly reassessing the patient's migraine frequency and severity to adjust the treatment plan as needed
- Considering the patient's individual factors, such as medical history, preferences, and cost, when selecting an acute treatment medication.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for Worsening Migraines on Nightly Topamax
- For patients experiencing worsening migraines while taking nightly Topamax (topiramate), adding a triptan or Nurtec (rimegepant)/Ubrelvy (ubrogepant) may be considered as a treatment option.
- Rimegepant, a calcitonin gene-related peptide (CGRP) receptor antagonist, has been shown to be effective in the acute treatment and preventive treatment of migraine, with a favorable safety profile 2, 3.
- Topiramate is an antiepileptic drug that has proven its efficacy and safety in the prophylactic treatment of episodic migraine, with little pharmacological interaction with other drugs and generally well tolerated by patients 4.
Efficacy of Rimegepant
- Rimegepant has been demonstrated to be effective in improving freedom from pain and the most bothersome symptom at 2 hours after dosing, with additional benefits in reducing photophobia and phonophobia 5.
- A post-hoc analysis of three phase 3 trials found that rimegepant was effective for the acute treatment of migraine in adults with a history of insufficient response to 1 or ≥2 triptans, as well as in current triptan users 6.
Considerations for Treatment
- When deciding between adding a triptan or Nurtec (rimegepant)/Ubrelvy (ubrogepant) to nightly Topamax, consider the patient's history of triptan treatment experience and potential contraindications or intolerances to triptans.
- Rimegepant may be a promising therapeutic option for patients who have experienced inadequate relief from other therapies or have contraindications to triptans 5, 6.