From the Guidelines
Nurtec (rimegepant) should not be used as a first-line treatment for migraine prophylaxis due to insufficient evidence supporting its effectiveness for this indication, as stated in the 2024 clinical practice guideline for the management of headache 1. When considering migraine prophylaxis, the guideline recommends candesartan or telmisartan, as well as erenumab, fremanezumab, or galcanezumab, due to strong evidence supporting their use 1. Some key points to consider for migraine prophylaxis include:
- The use of candesartan or telmisartan is strongly recommended for the prevention of episodic migraine 1.
- Erenumab, fremanezumab, or galcanezumab are also strongly recommended for the prevention of episodic or chronic migraine 1.
- Other options, such as intravenous eptinezumab, lisinopril, oral magnesium, topiramate, propranolol, valproate, memantine, atogepant, and onabotulinumtoxinA injection, are suggested due to weaker evidence, but may still be considered for migraine prophylaxis 1. It's essential to note that while Nurtec (rimegepant) is effective for the acute treatment of migraine, its use for prophylaxis is not supported by sufficient evidence, as indicated in the guideline 1.
From the FDA Drug Label
The efficacy of NURTEC ODT for the preventive treatment of episodic migraine in adults was demonstrated in one randomized, double-blind, placebo-controlled trial of a different oral dosage form of rimegepant (Study 2; NCT03732638). Rimegepant 75 mg dosed every other day demonstrated statistically significant improvements for these efficacy endpoints compared to placebo, as summarized in Table 3 Table 3: Efficacy Endpoints for the Preventive Treatment of Episodic Migraine in Study 2 Rimegepant 75 mg Every Other Day demonstrated a change from baseline in the mean number of monthly migraine days (MMDs) during Weeks 9 through 12 of -4.3, which was statistically significantly improved compared to placebo.
Nurtec (rimegepant) can be used for migraine prophylaxis. The primary efficacy endpoint for Study 2 was the change from baseline in the mean number of monthly migraine days (MMDs) during Weeks 9 through 12 of the double-blind treatment phase. Key findings include:
- A statistically significant reduction in monthly migraine days
- A statistically significant percentage of patients who achieved at least a 50% reduction from baseline in moderate to severe MMDs during Weeks 9 through 12 of the double-blind treatment phase compared to placebo 2
From the Research
Migraine Prophylaxis with Nurtec
- Nurtec (rimegepant) is a calcitonin gene-related peptide (CGRP) receptor antagonist that has been approved for the acute treatment of migraine with or without aura in adults, and for the preventive treatment of episodic migraine in adults 3.
- The drug has been shown to be effective in reducing the number of monthly migraine days when taken every other day for the preventive treatment of migraine 3.
- Rimegepant is generally well tolerated, with no evidence of hepatotoxicity or cardiovascular toxicity in clinical trials 3, 4.
- The use of rimegepant as an oral acute treatment in patients receiving CGRP monoclonal antibodies as preventive treatment has been found to be safe and well tolerated 4.
Comparison with Other Migraine Prophylaxis Options
- Traditional migraine prophylaxis options include beta-blockers, flunarizine, valproic acid, and topiramate, among others 5.
- CGRP monoclonal antibodies, such as erenumab, galcanezumab, and fremanezumab, have also been approved for migraine prevention 6.
- Rimegepant, as a small molecule CGRP receptor antagonist, offers a convenient and potentially faster-acting alternative to traditional prophylaxis options 3, 7.
Clinical Evidence and Safety
- Clinical trials have demonstrated the efficacy and safety of rimegepant for both acute and preventive treatment of migraine 3, 4, 7.
- The safety of rimegepant when used concomitantly with CGRP monoclonal antibodies has been evaluated, and no significant safety issues have been identified 4.
- Further studies are needed to confirm the long-term safety and efficacy of rimegepant for migraine prophylaxis 3, 6.