Is Nurtec an Abortive Medication?
Yes, Nurtec (rimegepant) is FDA-approved as an abortive medication for the acute treatment of migraine with or without aura in adults. 1
Dual Indication Profile
Rimegepant uniquely holds both abortive and preventive indications, making it the first dual-purpose agent in migraine management 2:
- Abortive use: 75 mg orally disintegrating tablet taken as needed when migraine occurs 1
- Preventive use: 75 mg taken every other day to reduce migraine frequency 1
Guideline Recommendations for Abortive Use
The 2023 VA/DoD Clinical Practice Guideline provides a "weak for" recommendation for rimegepant as an abortive therapy for short-term treatment of migraine 3. This places rimegepant in the escalation tier of abortive treatment, positioned after first-line options but as a viable alternative 4.
Treatment Algorithm Position
First-line abortive options (for mild-to-moderate migraine) 4:
- Aspirin-acetaminophen-caffeine combination (strong recommendation, NNT=9 for pain freedom at 2 hours) 3
- NSAIDs: ibuprofen 400-800 mg, naproxen sodium 275-550 mg 4
Escalation therapy (for moderate-to-severe migraine or NSAID failure) 4:
- Triptans remain first-line for escalation (strong recommendation) 3
- Rimegepant or ubrogepant as newer gepant options (weak for recommendation, NNT=13 for pain freedom at 2 hours) 3
Efficacy Data
In pivotal phase III trials, rimegepant 75 mg demonstrated statistically significant superiority over placebo 1:
- Pain freedom at 2 hours: 21.2% vs 10.9% placebo (p<0.001) 1
- Most bothersome symptom freedom at 2 hours: 35.1% vs 26.8% placebo (p=0.001) 1
- Pain relief at 2 hours: 59.3% vs 43.3% placebo (p<0.001) 1
- Sustained pain freedom 2-48 hours: 13.5% vs 5.4% placebo (p<0.001) 1
Mechanism of Action
Rimegepant functions as a calcitonin gene-related peptide (CGRP) receptor antagonist, blocking CGRP-mediated vasodilation and neuropeptide release in the trigeminal system 2, 5. This mechanism differs fundamentally from triptans (5-HT1B/1D agonists) and offers a critical advantage: rimegepant does not cause vasoconstriction 6.
Clinical Advantages
Key benefits over triptans 5, 6:
- No cardiovascular contraindications (safe in patients with vascular disease, uncontrolled hypertension, or coronary disease) 6
- Does not induce medication-overuse headache 6
- Orally disintegrating tablet formulation allows use without water 2, 5
- Can be used for both acute treatment and prevention 2
Safety Profile
Rimegepant demonstrates favorable tolerability 1, 5:
- Most common adverse effects: nausea, urinary tract infection, dizziness 5
- No evidence of hepatotoxicity in clinical trials 2
- No cardiovascular toxicity signals 2
- In 52-week studies, only 2.3% reported severe adverse events 7
Important Caveats
Therapeutic gain limitations: While statistically significant, rimegepant's absolute benefit over placebo is modest (approximately 10% improvement in pain freedom) 3, 6. The clinical significance of this effect should be weighed against cost and patient-specific factors 6.
CGRP blockade concerns: Since CGRP serves as a protective vasodilatory molecule during ischemia, long-term consequences of CGRP pathway blockade remain under investigation, particularly in patients with cardiovascular disease 6. However, current evidence through 52 weeks shows no cardiovascular adverse events 7.
Medication timing: Like all abortive therapies, rimegepant should be administered as early as possible after symptom onset to maximize efficacy 4.
Frequency limits: When used as an abortive agent, rimegepant should be limited to avoid medication overuse headache, though specific frequency thresholds are less established than for triptans (<10 days/month) or NSAIDs (<15 days/month) 4.