What is Reyvow (lasmiditan)?

Reyvow (Lasmiditan): A Third-Line Medication for Acute Migraine Treatment

Reyvow (lasmiditan) is a ditan-class medication that serves as a third-line treatment option for acute migraine attacks in adults when NSAIDs and triptans have failed or are contraindicated. It works as a selective 5-HT1F receptor agonist without the vasoconstrictive effects associated with triptans 1.

Mechanism and Classification

Lasmiditan represents the first medication in the ditan class, which differs from triptans in several important ways:

• Acts as a highly selective 5-HT1F receptor agonist 2
• Lacks vasoconstrictive activity, unlike triptans 3, 2
• Works through central and peripheral mechanisms to relieve migraine pain 3

Efficacy Profile

Lasmiditan has demonstrated effectiveness for acute migraine treatment:

• Pain freedom at 2 hours after dosing (comparable to triptans) 1
• Onset of pain relief as early as 30 minutes after 100mg or 200mg doses 3
• Improvement in most bothersome migraine symptoms (photophobia, phonophobia, nausea) 3
• Available in 50mg and 100mg oral tablet formulations 4

Place in Treatment Algorithm

According to current guidelines, lasmiditan should be positioned as follows:

1. First-line: NSAIDs (acetylsalicylic acid, ibuprofen, diclofenac potassium) 1
2. Second-line: Triptans (sumatriptan, rizatriptan, etc.) 1
3. Third-line: Ditans (lasmiditan) or gepants (ubrogepant, rimegepant) 1

Important Safety Considerations

Lasmiditan has several notable safety concerns that limit its widespread use:

• Associated with temporary driving impairment - patients should not operate machinery for at least 8 hours after taking the medication 1
• Low number needed to harm of 4 for treatment-emergent adverse effects 1
• Central nervous system side effects are common 2
• Not indicated for preventive treatment of migraine 5

Dosing Considerations

• Optimal dosing appears to be 200mg for achieving headache pain freedom at 2 hours and sustained pain freedom at 24 hours 6
• However, both 50mg and 100mg formulations are available and FDA-approved 4
• Should be taken early in the migraine attack for maximum effectiveness 1

Special Populations

Lasmiditan may be particularly valuable for:

• Patients with cardiovascular risk factors or stable cardiovascular disease who cannot take triptans due to their vasoconstrictive effects 6, 2
• Patients who have failed to respond to NSAIDs and triptans 7
• Patients who cannot tolerate triptans due to side effects 1

Clinical Pitfalls and Caveats

• Do not use lasmiditan for migraine prevention - it is only approved for acute treatment 5
• The driving restriction (8 hours post-dose) is a significant limitation that may discourage widespread use 1
• Patients may be unable to self-assess their driving competence after taking lasmiditan 1
• Balance the potential cardiovascular benefits against the increased central nervous system risks 2
• Consider cost implications - lasmiditan is significantly more expensive than NSAIDs or triptans 1

Lasmiditan represents an important addition to the migraine treatment armamentarium, particularly for patients who cannot use or do not respond to first and second-line therapies. However, its side effect profile and driving restrictions require careful patient selection and counseling.