What is the recommended dose of Relpax (eletriptan) for acute migraine attacks?

Relpax (Eletriptan) Dosing for Acute Migraine

The recommended dose of Relpax (eletriptan) is 40 mg as a single oral dose at the onset of migraine, with the option to repeat once after 2 hours if needed, not exceeding 80 mg total daily dose. 1

Standard Dosing Protocol

• Initial dose: 20 mg or 40 mg taken at migraine onset 1
• Maximum single dose: 40 mg 1
• Repeat dosing: If headache persists or returns after 2 hours, a second dose may be taken at least 2 hours after the first dose 1
• Maximum daily dose: 80 mg (total for the day) 1
• Monthly limit: Safety of treating more than 3 migraine attacks per 30-day period has not been established 1

Dose Selection Rationale

The 40 mg dose is superior to 20 mg for most efficacy endpoints and should be the preferred starting dose for moderate to severe migraine. 1, 2 Clinical trials demonstrate that 40 mg eletriptan provides significantly better pain-free response at 2 hours (NNT 4.5) compared to 20 mg (NNT 9.9), while maintaining acceptable tolerability. 3

• The 40 mg dose shows headache response rates of 54% at 2 hours and 28% pain-free rates 4
• The 80 mg dose (not FDA-approved as maximum single dose in US) shows higher efficacy (68% response, 38% pain-free) but also increased adverse effects 4
• Eletriptan 40 mg demonstrates superiority over naratriptan 2.5 mg and equivalence to almotriptan 12.5 mg, rizatriptan 10 mg, and zolmitriptan 2.5 mg 2, 5

Critical Timing Considerations

Administer eletriptan as early as possible during the migraine attack to maximize efficacy. 6, 7 The medication demonstrates superiority over placebo as early as 30 minutes after administration, with peak efficacy at 1-2 hours. 2, 5

Integration with Treatment Guidelines

• First-line approach: Current guidelines recommend NSAIDs as initial therapy for mild-to-moderate migraine 6, 7
• Triptan escalation: Eletriptan should be used when NSAIDs provide inadequate response or for moderate-to-severe attacks 6
• Combination therapy: Consider combining triptans with fast-acting NSAIDs to prevent recurrence, as 40% of patients experience symptom return within 48 hours 6, 7

Important Contraindications and Precautions

Do not use eletriptan in patients with ischemic coronary artery disease, uncontrolled hypertension, or within 24 hours of other triptans or ergot-containing medications. 1

• Contraindicated within 72 hours of potent CYP3A4 inhibitors (ketoconazole, itraconazole, clarithromycin, ritonavir) 1
• Contraindicated in patients with history of stroke, TIA, hemiplegic or basilar migraine, peripheral vascular disease, or ischemic bowel disease 1
• Perform cardiovascular evaluation in triptan-naïve patients with multiple cardiovascular risk factors before prescribing 1

Medication Overuse Headache Prevention

Limit eletriptan use to no more than 2 days per week (or 10 days per month for triptans) to prevent medication overuse headache. 6, 7 Patients requiring more frequent acute treatment should be evaluated for preventive therapy. 6

Available Formulations

• 20 mg tablets: Orange, round, film-coated, debossed 'EL 20' 1
• 40 mg tablets: Orange, round, film-coated, debossed 'EL 40' 1

When Eletriptan Fails

If eletriptan provides inadequate response after adequate trial, consider: 6, 7

• Trying a different triptan (failure of one does not predict failure of others) 7
• Escalating to third-line agents (CGRP antagonists-gepants, ditans, or dihydroergotamine) 6
• Initiating preventive therapy if attacks occur more than 2 days per month 6