What are the next steps for a patient on lamotrigine (improving migraines) and Ubrelvy (gepants, not working as well) for abortive therapy?

Management of Patient with Lamotrigine and Ineffective Ubrelvy for Migraines

For a patient on lamotrigine with improving migraines but experiencing decreased effectiveness of ubrogepant (Ubrelvy), the next step should be to switch to a different triptan medication, such as sumatriptan, rizatriptan, or zolmitriptan, while maintaining the lamotrigine therapy. 1

Current Treatment Assessment

• Lamotrigine is showing some benefit for migraine prevention, which aligns with evidence suggesting its effectiveness particularly for migraine with aura 2, 3
• Ubrogepant (Ubrelvy), a gepant-class medication, is becoming less effective as an abortive therapy 4
• This situation requires optimization of the acute treatment strategy while maintaining the beneficial preventive therapy 1

Recommended Treatment Algorithm

Step 1: Optimize Acute Treatment

• Switch from ubrogepant to a triptan medication as second-line therapy 1
  • Strong recommendations support triptans such as sumatriptan, rizatriptan, eletriptan, or zolmitriptan for acute migraine treatment 1
  • Consider starting with sumatriptan 50mg, which may provide optimal balance of efficacy and side effects 5
  • Triptans should be taken early in the headache phase for maximum effectiveness 1

Step 2: Consider Combination Therapy

• Add an NSAID (ibuprofen, naproxen, or diclofenac) to the triptan therapy to enhance effectiveness and prevent recurrence 1
• The combination of a triptan with an NSAID has shown superior efficacy compared to either medication alone 1

Step 3: If Triptan Therapy Fails

• Try a different triptan if the first one is ineffective, as response to triptans can vary between patients 1
• Consider subcutaneous sumatriptan for attacks that rapidly reach peak intensity or when oral medications cannot be taken due to vomiting 1

Step 4: Further Options if Needed

• If triptans are contraindicated or ineffective, consider returning to a different gepant (rimegepant or zavegepant) 1
• For severe nausea or vomiting, add a prokinetic antiemetic such as metoclopramide or domperidone 1

Preventive Treatment Optimization

• Continue lamotrigine if it is providing benefit for migraine prevention 2, 3
• Consider adding or switching to a more evidence-based preventive option if migraines remain inadequately controlled 1:
  • CGRP monoclonal antibodies (erenumab, fremanezumab, or galcanezumab) have strong evidence for prevention 1
  • Topiramate, propranolol, or valproate are also well-established options 1
  • Atogepant could be considered as a newer preventive option 1

Important Considerations and Cautions

• Avoid using acute medications more than twice weekly to prevent medication overuse headache 1
• Avoid opioids and barbiturates for migraine treatment due to limited efficacy and risk of dependency 1
• Monitor for drug interactions between lamotrigine and any new medications added to the regimen 6
• The combination of preventive (lamotrigine) and acute treatment (triptan plus NSAID) should be safe, but the concomitant use of multiple CGRP antagonists (like atogepant and ubrogepant) requires careful monitoring 7

Follow-up Recommendations

• Reassess effectiveness of the new acute treatment after 2-4 weeks 1
• If migraines remain poorly controlled despite optimized acute and preventive therapy, consider referral to a headache specialist 1
• Document frequency, severity, and response to treatment to guide further management decisions 1