What is the recommended dosage and usage of Reyvow (lasmiditan) for acute migraine treatment in adults?

Reyvow (Lasmiditan) Dosing and Usage for Acute Migraine

Recommended Dosage

Reyvow (lasmiditan) is available in 50 mg and 100 mg oral tablets for the acute treatment of migraine with or without aura in adults. 1, 2 The FDA-approved doses are 50 mg, 100 mg, and 200 mg, with the 200 mg dose demonstrating superior efficacy to 100 mg without significantly increased adverse events. 3, 4

Dose Selection

• Start with 50 mg or 100 mg based on individual patient factors and tolerability concerns 1, 2
• The 200 mg dose is more effective for pain freedom at 2 hours compared to 100 mg (34.53% vs 28.67%), though it carries a higher risk of treatment-emergent adverse events 3, 4
• The 50 mg dose has an efficacy rate of approximately 50% in real-world practice, with lower side effect burden 5

Clinical Positioning in Treatment Algorithm

Lasmiditan should be reserved as a third-line medication for patients who have failed or cannot tolerate all other recommended acute migraine treatments. 6

Specific Indications for Use

• Use lasmiditan only after inadequate response or intolerance to:

  • First-line: NSAIDs (aspirin, ibuprofen, diclofenac) or acetaminophen 6
  • Second-line: Combination therapy of triptan + NSAID or acetaminophen 6
  • Alternative options: CGRP antagonists (gepants) or dihydroergotamine 6

• Lasmiditan is particularly valuable for patients with cardiovascular contraindications to triptans, as it lacks vasoconstrictive activity 7, 2

Timing and Administration

• Administer as early as possible after migraine onset when headache is moderate to severe 6
• Efficacy begins as early as 30 minutes for pain relief and most bothersome symptom freedom with 100-200 mg doses 8
• Peak efficacy occurs at 2 hours, with significantly higher rates of pain freedom (100 mg: 28.67%; 200 mg: 34.53%) compared to placebo (17.55%) 3, 8

Critical Safety Restrictions

Patients must not drive or operate machinery for at least 8 hours after taking lasmiditan due to CNS effects and driving impairment. 6, 7 This is a mandatory restriction, as patients may be unable to self-assess their driving competence. 6

Common Adverse Effects

• CNS side effects are frequent and dose-dependent: 3, 4

  • Dizziness, somnolence, fatigue, and paresthesia occur more commonly than placebo
  • Overall incidence of side effects: 66.7% with 50 mg dose 5
  • Dropout rate due to side effects: 37% in real-world practice 5

• Mild somnolence may predict efficacy - if this is the only side effect, continuation may be beneficial 5

Patient Selection Factors

Lasmiditan is more likely to be effective in:

• Male patients 5
• Those with severe migraine classification 5
• Patients receiving concurrent anti-CGRP monoclonal antibody treatment 5

Contraindications and Precautions

• Do not use in pregnant or breastfeeding women 6
• Not indicated for migraine prevention - only for acute treatment 2
• Risk of medication overuse headache exists with frequent use (≥10 days per month threshold for acute medications) 6

Adjunctive Therapy

• Combine with prokinetic antiemetics (domperidone or metoclopramide) if nausea or vomiting is present 6, 7
• Consider preventive therapy if migraine attacks occur frequently despite adequate acute treatment 6, 7

Common Pitfalls to Avoid

• Do not use lasmiditan as first-line therapy - it is reserved for treatment-refractory patients only 6, 7
• Do not allow patients to drive within 8 hours of dosing, regardless of how they feel 6, 7
• Do not prescribe if adequate trials of triptans have not been attempted (at least 3 consecutive attacks with insufficient response) 6
• Do not use during the aura phase - wait until headache begins 6