Abortive Treatments for Migraines in Patients Taking Nurtec (Rimegepant)
For patients taking Nurtec (rimegepant) for migraine prevention, NSAIDs are the recommended first-line abortive treatment for breakthrough migraine attacks, with aspirin-acetaminophen-caffeine combination being strongly recommended as an effective option. 1, 2
First-Line Abortive Options for Patients on Nurtec
NSAIDs
- Ibuprofen: 400-800 mg every 6 hours (maximum 2.4g daily)
- Naproxen sodium: 275-550 mg every 2-6 hours (maximum 1.5g daily)
- Aspirin: 650-1000 mg every 4-6 hours (maximum 4g daily) 2
Combination Analgesics
- Aspirin-acetaminophen-caffeine combination (e.g., Excedrin Migraine) - strongly recommended based on significant improvement in pain freedom at 2 hours (NNT of 9) and pain relief at 2 hours (NNT of 4) 1
Important Considerations
Drug Interaction Concerns
When using rimegepant (Nurtec) for migraine prevention, it's crucial to avoid using another gepant medication (such as ubrogepant) for acute treatment due to the same mechanism of action. This would be redundant and potentially increase side effects.
Triptans Contraindication
Triptans should NOT be used as abortive treatment in patients taking Nurtec (rimegepant) due to potential drug interactions. Both medications work on similar pathways, and concurrent use could lead to decreased efficacy or increased adverse effects.
Second-Line Options
Antiemetics for Associated Symptoms
- Metoclopramide (Reglan): Useful for treating accompanying nausea and improving gastric motility 1
- Prochlorperazine (Compazine): Can effectively relieve headache pain and treat nausea 1
Non-Pharmacological Approaches
- Sleep can be an effective adjunctive therapy for migraine attacks 1
- Application of cold or pressure to the head or neck
- Minimizing sensory stimulation (light, sound)
Medication Limitations to Prevent Overuse Headache
- NSAIDs: Limit to no more than 15 days per month
- OTC medications (e.g., Excedrin Migraine): Limit to no more than 14 days per month 2
Special Considerations
Timing of Treatment
Take abortive medications early in the attack while pain is still mild for better efficacy 1
Severe Attacks with Vomiting
For severe attacks with significant nausea/vomiting where oral medications may not be effective:
- Non-oral routes of administration should be considered
- Greater occipital nerve blockade may be beneficial (weak recommendation) 1
Pitfalls to Avoid
- Using another gepant medication (like ubrogepant) for acute treatment in patients already on Nurtec
- Using triptans concurrently with Nurtec
- Exceeding recommended monthly limits of abortive medications, which can lead to medication overuse headache
- Using opioids or barbiturates, which have questionable efficacy and significant risk of dependence 1
- Failing to consider GI risk factors before prescribing NSAIDs, especially in patients with renal impairment, heart failure, or hypertension 2
By following this algorithm for abortive treatment in patients taking Nurtec, you can effectively manage breakthrough migraine attacks while minimizing the risk of drug interactions and medication overuse headache.