Can Nurtec (rimegepant) be taken with a triptan?

Nurtec (Rimegepant) Should Not Be Taken With a Triptan

Nurtec (rimegepant) should not be taken concurrently with triptans due to their overlapping mechanisms of action and lack of evidence supporting combination therapy safety and efficacy. 1, 2

Rationale for Not Combining Nurtec with Triptans

Nurtec (rimegepant) and triptans work through different but related mechanisms for migraine treatment:

• Different medication classes:

  • Triptans are serotonin (5-HT1B/1D) receptor agonists
  • Rimegepant is a calcitonin gene-related peptide (CGRP) receptor antagonist (gepant)

• Therapeutic positioning:

  • Triptans are considered second-line therapy for migraine after NSAIDs/acetaminophen 1
  • Gepants like rimegepant are positioned as third-line therapy for patients who fail or cannot tolerate triptans 1

Treatment Algorithm for Acute Migraine

1. First-line: NSAIDs (ibuprofen, naproxen, diclofenac) or acetaminophen
2. Second-line: Triptans (sumatriptan, rizatriptan, etc.)
3. Third-line: CGRP antagonists (rimegepant, ubrogepant) for those who:
   • Do not respond adequately to triptans
   • Have contraindications to triptans
   • Cannot tolerate triptan side effects

Why Combining Is Not Recommended

1. Lack of evidence: No clinical trials have established the safety or efficacy of combining triptans with gepants 2

2. Overlapping mechanisms: Both medication classes affect the migraine pathway, potentially leading to:

   • Unknown drug interactions
   • Unpredictable efficacy
   • Possible increased side effects

3. Clinical guidelines: Current guidelines position these medications as alternatives to each other, not as combination therapy 1

4. Practical considerations:

   • Both are effective as monotherapy in appropriate patients
   • Using both simultaneously could increase medication costs without proven benefit
   • May increase risk of medication overuse headache

Important Clinical Considerations

• Triptan non-responders: Patients who don't respond to triptans can switch to rimegepant rather than combining medications 2, 3

• Cardiovascular risk: For patients with cardiovascular contraindications to triptans, rimegepant may be used as an alternative (not in addition) 2, 4

• Timing: If a patient has taken a triptan that failed to relieve a migraine attack, they should wait until the next migraine attack to try rimegepant rather than adding it to the same attack

• Medication overuse: Using multiple acute migraine medications increases the risk of medication overuse headache 1

Alternative Approaches

• If triptans alone are insufficient, consider combining triptans with NSAIDs or acetaminophen instead 1
• For patients with inadequate response to triptans, switching completely to rimegepant is appropriate 3
• For severe nausea/vomiting, consider non-oral triptans with an antiemetic rather than adding rimegepant 1

Remember that the goal of migraine treatment is to find the most effective monotherapy or approved combination that provides adequate relief with minimal side effects and risk.