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

Nurtec (Rimegepant) for Migraine Treatment

Nurtec (rimegepant) is a third-line medication reserved for patients who fail or cannot tolerate combination therapy with a triptan plus NSAID or acetaminophen. 1

Position in Treatment Algorithm

Rimegepant should only be considered after the following stepwise approach has been attempted:

• First-line: Start with NSAIDs (ibuprofen, naproxen) or acetaminophen for moderate to severe migraine 1
• Second-line: Add a triptan to an NSAID (or to acetaminophen if NSAIDs are contraindicated) when first-line therapy provides inadequate relief 1
• Third-line: Consider rimegepant only after documented failure or intolerance to triptan-NSAID combination therapy 1

The American College of Physicians found uncertain comparative effectiveness data for CGRP antagonists like rimegepant, with evidence suggesting they may have lower likelihood of pain freedom at 2 hours compared to triptan-NSAID combinations. 1

FDA-Approved Indications and Dosing

Rimegepant has two distinct FDA-approved uses: 2

Acute Treatment

• Dose: 75 mg orally disintegrating tablet taken as needed 2
• Maximum: 75 mg in any 24-hour period 2
• Safety limit: No more than 18 doses in a 30-day period 2

Preventive Treatment

• Dose: 75 mg taken every other day 2

Administration Instructions

The orally disintegrating tablet formulation offers convenience: 2

• Use dry hands to peel back foil (do not push tablet through)
• Place tablet on or under tongue immediately after opening
• Tablet dissolves in saliva without need for water
• Do not store outside blister pack

Critical Drug Interactions

Avoid or adjust dosing with the following: 2

• Strong CYP3A4 inhibitors: Avoid concomitant use entirely
• Moderate CYP3A4 inhibitors: Avoid another dose within 48 hours
• Strong/moderate CYP3A inducers: Avoid concomitant use (may cause loss of efficacy)
• Potent P-gp inhibitors: Avoid another dose within 48 hours

Safety Considerations

Contraindications: 2

• History of hypersensitivity to rimegepant or any component
• Delayed serious hypersensitivity reactions (dyspnea, rash) can occur days after administration

Hepatic impairment: 2, 3

• Avoid use in severe hepatic impairment (Child-Pugh C)
• Exposures increase 2-3.9 fold in severe impairment

Medication overuse headache: 1

• Limit acute treatments to no more than twice weekly
• The specific threshold for gepant-induced medication overuse headache has not been definitively established, but caution is warranted with frequent use

Clinical Efficacy Data

In phase 3 trials, rimegepant demonstrated superiority over placebo: 4

• Pain freedom at 2 hours: 21% vs 11% placebo (p<0.0001)
• Freedom from most bothersome symptom at 2 hours: 35% vs 27% placebo (p=0.0009)
• Tolerability: Similar to placebo with nausea being the most common adverse event (2%)

Long-term safety data showed rimegepant was well tolerated for up to 52 weeks, including in patients with prior triptan failures and those using concomitant preventive medications. 5, 6

Key Clinical Pitfalls to Avoid

Do not use rimegepant as first-line therapy - this contradicts current evidence-based guidelines that prioritize more effective and cost-efficient options. 1

Do not prescribe for pregnant or lactating patients - the guideline recommendations specifically apply to nonpregnant, nonlactating adults. 1

Do not allow frequent use without preventive therapy - if patients require acute treatment more than twice weekly, preventive medications should be initiated rather than increasing acute medication frequency. 1

Counsel early administration - like all acute migraine treatments, rimegepant should be taken as soon as possible after migraine onset for optimal efficacy. 1