What is the recommended dose of Nurtec (rimegepant) for abortive treatment of migraine?

Nurtec (Rimegepant) for Abortive Migraine Treatment

Recommended Dose

For acute treatment of migraine, the recommended dose of Nurtec ODT (rimegepant) is 75 mg taken orally as needed, with a maximum of one dose (75 mg) in a 24-hour period. 1

Administration Details

• Place the orally disintegrating tablet on or under the tongue immediately after opening the blister pack, where it will dissolve in saliva without requiring additional liquid 1
• Use dry hands when opening the blister pack and peel back the foil covering—do not push the tablet through the foil 1
• Do not store the tablet outside the blister pack for future use 1

Frequency Limitations

• The safety of using more than 18 doses in a 30-day period has not been established 1
• This frequency restriction is critical to avoid potential medication-overuse headache, which can develop from frequent use of acute migraine medications 2

Evidence Supporting Efficacy

• The 2023 VA/DoD guidelines provide a "weak for" recommendation for rimegepant as an abortive therapy, based on systematic reviews demonstrating a number needed to treat of 13 for pain freedom at 2 hours 2
• In the pivotal phase 3 trial, 19.6% of patients achieved pain freedom at 2 hours with rimegepant versus 12.0% with placebo (absolute difference 7.6 percentage points, p<0.001) 3
• Freedom from most bothersome symptom at 2 hours occurred in 37.6% with rimegepant versus 25.2% with placebo (absolute difference 12.4 percentage points, p<0.001) 3

Important Drug Interactions

• Avoid concomitant use with strong CYP3A4 inhibitors 1
• Avoid another dose within 48 hours when used with moderate CYP3A4 inhibitors (such as erythromycin, fluconazole, or grapefruit juice) 1
• Avoid another dose within 48 hours when used with potent P-glycoprotein inhibitors 1
• Avoid use with strong or moderate CYP3A inducers, which may reduce rimegepant efficacy 1

Contraindications and Safety

• Contraindicated in patients with a history of hypersensitivity to rimegepant or any component of Nurtec ODT 1
• Delayed serious hypersensitivity reactions can occur days after administration—discontinue immediately if hypersensitivity develops 1
• Long-term safety data from 1800 participants showed most adverse events were mild or moderate, with upper respiratory tract infection (8.8%), nasopharyngitis (6.8%), and sinusitis (5.1%) being most common 4
• No signal of hepatotoxicity, drug abuse potential, or medication-overuse headache was identified in long-term studies 4

Clinical Context

• Rimegepant represents a newer option among gepants (CGRP receptor antagonists) for acute migraine treatment 2
• While the 2023 VA/DoD guidelines give a "weak for" recommendation, this reflects the moderate strength of evidence rather than lack of efficacy—the benefits are clinically meaningful but the number needed to treat is higher than for some established therapies like triptans 2
• The most common adverse events in clinical trials were nausea and urinary tract infection, with a safety profile similar to placebo 3