What are the alternatives to Nurtec (rimegepant) for the acute treatment of migraine attacks?

Alternatives to Nurtec (Rimegepant) for Acute Migraine Treatment

For most migraine sufferers, nonsteroidal anti-inflammatory drugs (NSAIDs) are the recommended first-line therapy for acute treatment of migraine attacks, followed by triptans as second-line therapy when NSAIDs fail or for moderate to severe attacks. 1, 2

First-Line Options

NSAIDs

• Ibuprofen: 400-600mg
• Naproxen sodium: 500-550mg
• Aspirin
• Acetaminophen-aspirin-caffeine combination

NSAIDs have the most consistent evidence for effectiveness in acute migraine treatment 1. They are generally well-tolerated and cost-effective compared to newer agents.

Note: Acetaminophen alone is ineffective for migraine treatment 2

Second-Line Options (When NSAIDs Fail)

Triptans

• Sumatriptan: 6mg subcutaneously or 50mg orally
• Rizatriptan: 10mg orally
• Naratriptan: oral formulation
• Zolmitriptan: oral formulation

Triptans should be used when migraine attacks have not responded to NSAIDs or for moderate to severe attacks 1, 2. They are migraine-specific agents with good evidence for efficacy.

Important Triptan Contraindications

• Uncontrolled hypertension
• Basilar or hemiplegic migraine
• Cardiovascular disease or risk factors
• Concurrent use with MAO-A inhibitors

Third-Line Options (CGRP Antagonists - Gepants)

Alternatives to Rimegepant (Nurtec)

1. Ubrogepant (Ubrelvy)

   • FDA-approved for acute treatment of migraine with or without aura in adults 3
   • Dosing: 50mg or 100mg orally
   • Demonstrated efficacy for pain freedom and most bothersome symptom relief at 2 hours post-dose 3
   • Does not cause vasoconstriction, making it suitable for patients with cardiovascular risk factors 4

2. Zavegepant

   • Newer CGRP antagonist in the same class as rimegepant 1
   • May be considered for patients who don't respond to rimegepant

3. Lasmiditan (Reyvow)

   • First-in-class 5-HT1F receptor agonist (ditan) 5
   • Unlike triptans, does not cause vasoconstriction 5
   • Particularly useful for patients with cardiovascular risk factors where triptans are contraindicated 5
   • Common side effects include dizziness, paresthesia, somnolence, and fatigue 4
   • Driving restrictions apply due to CNS effects 4

Rescue Medications (For Severe Attacks)

• Opioids (e.g., meperidine)
• Butalbital-containing compounds

These should be reserved for severe migraine attacks that don't respond to first-line or second-line treatments 2.

Medication Usage Limitations to Prevent Medication Overuse Headache

• Triptans: No more than 9 days per month
• OTC medications (e.g., ibuprofen): No more than 14 days per month
• NSAIDs: No more than 15 days per month
• Ubrogepant: No more than 8 days per month 2

Selection Algorithm

1. Start with NSAIDs for mild to moderate attacks
2. Progress to triptans if NSAIDs fail or for moderate to severe attacks
3. Consider gepants (ubrogepant or zavegepant) or lasmiditan for:
   • Patients who don't respond to triptans
   • Patients with cardiovascular risk factors where triptans are contraindicated
   • Patients who experience intolerable side effects from triptans
4. Use rescue medications only for severe attacks unresponsive to other treatments

Clinical Considerations

• The newest agents (gepants and ditans) offer advantages for patients with cardiovascular risk factors but are generally more expensive than traditional options 4
• Lasmiditan's adverse effect profile (CNS effects) may limit its use in some patients 4
• No head-to-head studies have directly compared the newer agents (gepants and ditans) with triptans 4
• Consider non-oral routes of administration (subcutaneous, nasal) for patients with significant nausea or vomiting 1
• Antiemetics should be used concomitantly when nausea is a significant component of the migraine attack 1