What is Nurtec (rimegepant)?

Nurtec (Rimegepant): A CGRP Receptor Antagonist for Migraine Treatment

Nurtec ODT (rimegepant) is an FDA-approved calcitonin gene-related peptide (CGRP) receptor antagonist used for both acute treatment of migraine attacks with or without aura and preventive treatment of episodic migraine in adults. 1

Mechanism and Formulation

Rimegepant is a highly selective CGRP receptor antagonist that works by blocking the CGRP pathway, which is implicated in migraine pathogenesis. 2 It is available as an orally disintegrating tablet (ODT) that:

• Contains 75 mg of rimegepant
• Dissolves on or under the tongue without requiring water
• Offers convenience and potentially faster response compared to conventional tablets 2

FDA-Approved Indications

Nurtec ODT is approved for:

1. Acute treatment of migraine attacks with or without aura in adults
2. Preventive treatment of episodic migraine in adults 1

This dual indication makes Nurtec unique as the first medication approved for both acute and preventive migraine treatment. 2

Place in Therapy

According to current guidelines, Nurtec (rimegepant) is positioned as follows:

For Acute Treatment:

• Third-line therapy after patients have tried:

  1. First-line: NSAIDs, acetaminophen, or combination of NSAID and acetaminophen
  2. Second-line: Triptans (alone or combined with NSAIDs/acetaminophen) 3

• Consider Nurtec when patients:

  • Do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID/acetaminophen 3
  • Have contraindications to triptans 4

For Preventive Treatment:

• Later-line option after trials of:
  • β-blockers (metoprolol or propranolol)
  • Antiseizure medications (valproate)
  • SNRIs (venlafaxine)
  • TCAs (amitriptyline) 3

Dosing and Administration

• Acute treatment: 75 mg (one tablet) as needed, maximum one tablet in 24 hours
• Preventive treatment: 75 mg (one tablet) every other day 1

To take Nurtec ODT:

1. Use dry hands to open the blister pack
2. Peel back foil covering (do not push tablet through foil)
3. Place tablet on or under tongue immediately after opening
4. Allow to dissolve (no water needed) 1

Efficacy

Acute Treatment:

• Pain freedom at 2 hours: 19.6-21% (vs. 11-12% with placebo) 5, 6
• Freedom from most bothersome symptom at 2 hours: 35-37.6% (vs. 25.2-27% with placebo) 5, 6

Preventive Treatment:

• Reduction in monthly migraine days: 4.3 days (vs. 3.5 days with placebo)
• ≥50% responder rate: 49.1% (vs. 41.5% with placebo) 1

Safety and Adverse Effects

Most common side effects:

• Acute treatment: Nausea
• Preventive treatment: Nausea, stomach pain, indigestion 1

Serious adverse effects:

• Allergic reactions (including trouble breathing, rash, swelling of face/mouth/tongue/throat) can occur days after taking Nurtec ODT 1

No evidence of hepatotoxicity or cardiovascular toxicity was observed in clinical trials. 2

Important Considerations and Precautions

• Not recommended in patients with severe liver or kidney impairment
• Safety in pregnancy is not established; a pregnancy registry (MONITOR) is available
• Small amounts pass into breast milk
• Store at room temperature between 68°F to 77°F (20°C to 25°C) 1

Advantages Over Other Migraine Treatments

• Dual indication for both acute and preventive treatment
• No cardiovascular contraindications (unlike triptans)
• No risk of medication overuse headache (unlike triptans, which can cause this with ≥10 days of use per month)
• No sedation or driving restrictions (unlike lasmiditan) 3, 2

Nurtec represents an important alternative for patients who cannot tolerate or do not respond adequately to traditional migraine treatments, offering a novel mechanism of action with a favorable side effect profile.