Can you take Nurtec (rimegepant) PRN with Qulipta (atogepant) for chronic migraine?

Concurrent Use of Nurtec (Rimegepant) PRN with Qulipta (Atogepant) for Chronic Migraine

Yes, you can take Nurtec (rimegepant) PRN alongside Qulipta (atogepant) for chronic migraine, as these medications work through similar mechanisms but have different approved indications and can complement each other in treatment.

Understanding the Medications

Qulipta (Atogepant)

• Primary Use: Preventive treatment for episodic migraine
• Mechanism: CGRP receptor antagonist (gepant)
• Administration: Daily oral medication
• Evidence: The VA/DoD guidelines suggest atogepant for the prevention of episodic migraine (weak for recommendation) 1
• Efficacy: Demonstrated efficacy in reducing monthly migraine days within the first 4 weeks of treatment 2

Nurtec ODT (Rimegepant)

• Primary Use: Acute treatment of migraine with or without aura
• Secondary Use: Preventive treatment when taken every other day
• Mechanism: CGRP receptor antagonist (gepant)
• Administration: As-needed for acute attacks or every other day for prevention
• Evidence: The VA/DoD guidelines note insufficient evidence to recommend for or against rimegepant for prevention 1, but suggest rimegepant for short-term treatment of migraine 1

Rationale for Combination Therapy

1. Different Treatment Purposes:

   • Atogepant (Qulipta) provides continuous preventive coverage
   • Rimegepant (Nurtec) addresses breakthrough migraine attacks

2. Complementary Approach:

   • This combination provides both preventive and acute treatment options
   • Similar to traditional approaches using preventive medications with acute rescue medications

3. Evidence Support:

   • The VA/DoD guidelines suggest rimegepant for short-term treatment of migraine 1
   • The American College of Physicians suggests gepants (including rimegepant) for the short-term treatment of migraine 1

Important Considerations

Potential Concerns

• Both medications target the same pathway (CGRP), which theoretically could increase the risk of side effects
• Limited published data on the specific combination of atogepant and rimegepant
• Cost considerations as both are newer, branded medications

Monitoring Recommendations

• Track frequency and severity of migraine attacks using a headache diary
• Monitor for common side effects including:
  • Nausea
  • Constipation
  • Upper respiratory tract infections
  • Fatigue

Medication Overuse Risk

• Be aware of medication overuse headache risk
• Limit acute medication use (including Nurtec) to fewer than 10 days per month

Alternative Approaches

If the combination is not effective or tolerated:

1. Consider other preventive options:

   • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab)
   • Topiramate
   • Beta-blockers (propranolol)
   • OnabotulinumtoxinA for chronic migraine

2. Alternative acute treatments:

   • Triptans (if not contraindicated)
   • NSAIDs
   • Combination analgesics (aspirin-acetaminophen-caffeine)

Conclusion

The combination of Nurtec (rimegepant) PRN with Qulipta (atogepant) represents a rational approach to chronic migraine management, providing both preventive coverage and acute treatment options. While both target the CGRP pathway, their different approved indications and dosing schedules make them complementary in addressing different aspects of migraine management.