What is the recommended dosage and usage of Zavzpret (lasmiditan) and Reyvow (lasmiditan) for migraine treatment?

Zavzpret and Reyvow for Migraine Treatment: Dosage and Usage

There is insufficient evidence to recommend either Zavzpret (zavegepant) or Reyvow (lasmiditan) as first-line treatments for acute migraine attacks, and they should only be considered after failure of recommended first-line therapies. 1

Current Treatment Algorithm for Acute Migraine

First-Line Treatments

1. NSAIDs or Acetaminophen

   • Start with adequate dosing of NSAIDs (ibuprofen, naproxen, aspirin) or acetaminophen
   • Ensure proper dosing before determining treatment failure 1

2. First-Line Combination

   • If monotherapy fails, add a triptan to an NSAID or acetaminophen
   • Triptans with strong recommendation: eletriptan, frovatriptan, rizatriptan, sumatriptan, zolmitriptan 1
   • Aspirin-acetaminophen-caffeine combinations are also strongly recommended 1

Second-Line Treatments

1. CGRP Antagonists (Gepants)

   • Consider Zavzpret (zavegepant) only after failure of first-line therapies 1
   • Used for moderate to severe acute episodic migraine in patients who don't respond to or tolerate combination therapy 1

2. Ditans

   • Consider Reyvow (lasmiditan) only after failure of all other pharmacologic treatments 1
   • Reserved as one of the last options for acute migraine treatment 1

Zavzpret (Zavegepant) Information

• Drug Class: CGRP antagonist (gepant)
• Formulation: Intranasal spray
• When to Use: After failure of triptans plus NSAIDs/acetaminophen 1
• Key Advantage: May be suitable for patients with cardiovascular contraindications to triptans as it doesn't cause vasoconstriction 1
• Cost Consideration: Significantly higher cost than first-line treatments (annualized WAC approximately $8,800 for intranasal spray) 1

Reyvow (Lasmiditan) Information

• Drug Class: First in class "ditan" (selective 5-HT1F receptor agonist) 2, 3
• Formulation: Oral tablets (50 mg and 100 mg) 4
• When to Use: Last resort after failure of all other treatments including triptans and gepants 1
• Key Advantage: Does not cause vasoconstriction, making it potentially suitable for patients with cardiovascular conditions where triptans are contraindicated 5
• Important Cautions:
  • May cause significant CNS side effects
  • Cannot drive for at least 8 hours after taking the medication
  • Not for preventive treatment of migraine 4

Clinical Pearls

• Both medications have shown efficacy compared to placebo in clinical trials, but have limited comparative data against first-line treatments 1
• Lasmiditan has demonstrated comparable efficacy in patients who previously had good or insufficient responses to triptans 6
• Treatment should begin as soon as possible after migraine onset for best results 1
• Patients should try a medication for 2-3 headache episodes before determining its effectiveness 1
• Be aware of medication overuse headache risk (≥10 days/month with triptans) 1

Common Pitfalls to Avoid

1. Skipping first-line treatments: Don't jump to newer, more expensive medications before adequately trialing established treatments
2. Ignoring cardiovascular status: While lasmiditan and zavegepant don't cause vasoconstriction like triptans, they have their own safety considerations
3. Overlooking driving restrictions: Patients taking lasmiditan cannot drive for at least 8 hours after dosing
4. Using for prevention: Both medications are only approved for acute treatment, not prevention of migraine
5. Cost burden: Consider the significantly higher cost of these newer medications compared to established treatments

Remember that the current evidence and guidelines suggest these newer medications should be reserved for patients who have failed or cannot tolerate first-line therapies, despite their novel mechanisms of action.