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 dose for acute migraine attacks, with the option to take a second 40 mg dose at least 2 hours after the first if the headache persists or returns, not exceeding a maximum daily dose of 80 mg. 1

FDA-Approved Dosing Regimen

• Initial dose options: 20 mg or 40 mg as a single dose 1
• 40 mg is more effective than 20 mg: Clinical trials demonstrated that a greater proportion of patients achieved headache response with 40 mg compared to 20 mg 1
• Second dose timing: If the migraine has not resolved by 2 hours after the initial dose, or returns after transient improvement, a second dose may be taken at least 2 hours after the first dose 1
• Maximum daily dose: 80 mg per day 1
• Frequency limitation: The safety of treating more than 3 migraine attacks in a 30-day period has not been established 1

Clinical Efficacy Data

Headache response at 2 hours (reduction from moderate/severe to mild/no pain):

• Eletriptan 20 mg: 47-54% of patients 1
• Eletriptan 40 mg: 54-66% of patients 1
• Eletriptan 80 mg: 59-77% of patients 1
• Placebo: 20-40% of patients 1

Pain-free response at 2 hours:

• Number-needed-to-treat (NNT) for 40 mg: 4.5 patients 2
• Number-needed-to-treat (NNT) for 80 mg: 3.7 patients 2

Onset of action: Eletriptan demonstrates superiority over placebo as early as 30 minutes after administration of 40 mg or 80 mg doses 3, 4

Comparative Effectiveness

• Eletriptan 40 mg showed greater efficacy than sumatriptan 50-100 mg for most endpoints 3, 4
• Eletriptan 40 mg was generally superior to naratriptan 2.5 mg 3, 4
• Eletriptan 40 mg was equivalent to almotriptan 12.5 mg, rizatriptan 10 mg, and zolmitriptan 2.5 mg 3, 4
• Eletriptan 40 mg and 80 mg were consistently superior to ergotamine/caffeine (Cafergot) 3, 4, 5

Guideline Context for Triptan Use

Triptans are recommended as second-line therapy after NSAIDs for moderate to severe migraine 6

• First-line treatment should be NSAIDs (aspirin, ibuprofen, or diclofenac) 6
• Triptans should be used when NSAIDs provide inadequate response 6
• Combination therapy with triptans plus NSAIDs or acetaminophen is recommended to improve efficacy and prevent recurrence 6
• Treatment should begin as early as possible during the attack for maximum effectiveness 6

Critical Safety Considerations

Absolute contraindications to eletriptan: 1

• Ischemic coronary artery disease, history of myocardial infarction, or Prinzmetal's angina
• History of stroke or transient ischemic attack
• Peripheral vascular disease or ischemic bowel disease
• Uncontrolled hypertension
• Use within 24 hours of another triptan, ergotamine, or DHE
• Use within 72 hours of potent CYP3A4 inhibitors (ketoconazole, itraconazole, clarithromycin, ritonavir, nelfinavir)

Medication Overuse Headache Prevention

Limit acute medication use to no more than 2 days per week to prevent medication-overuse headache 6

• Using triptans ≥10 days per month can lead to medication-overuse headache 6
• If frequent attacks require more than twice-weekly treatment, preventive therapy should be initiated 6

Adverse Effects

• Minor adverse effects occur in a dose-dependent manner with NNH of 7.0 for 40 mg and 3.7 for 80 mg 2
• No significant difference in major adverse effects compared to placebo 2
• Adverse events are generally mild or moderate and transient 5