Can a patient with a persistent migraine take Maxalt (Rizatriptan) an hour after taking Nurtec (Ubrogepant) that did not abort the migraine?

Can Maxalt Be Taken After Failed Nurtec?

Yes, you can take Maxalt (rizatriptan) after Nurtec (ubrogepant) fails to abort a migraine, as there is no pharmacologic contraindication to using both medications in the same patient, and guidelines support having both available for rescue therapy. 1

Evidence-Based Rationale

No Drug Interaction Concerns

• The Department of Veterans Affairs and Department of Defense guidelines explicitly state there is no pharmacologic contraindication to having both rimegepant (Nurtec) and rizatriptan (Maxalt) available to the same patient 1
• These medications work through different mechanisms: ubrogepant blocks CGRP receptors while rizatriptan is a 5-HT1B/1D receptor agonist, making concurrent or sequential use mechanistically safe 2, 3

Guideline Support for Sequential Use

• The American College of Physicians recommends rizatriptan as first-line acute therapy with strong evidence, while rimegepant is suggested as an alternative when triptans are contraindicated or poorly tolerated 1
• Current guidelines recommend rizatriptan for acute rescue therapy even in patients using rimegepant for prevention 1
• The 2024 VA/DoD guidelines provide strong recommendations for rizatriptan and weak recommendations for ubrogepant for short-term migraine treatment, suggesting rizatriptan as the more robust option 4

Practical Implementation

Timing Considerations

• Rizatriptan reaches peak blood concentration in 60-90 minutes and shows onset of effect as early as 30 minutes after dosing 4, 5
• Waiting one hour after failed ubrogepant is reasonable, though no specific waiting period is mandated by guidelines 1

Dosing Parameters

• Use rizatriptan 10 mg as the standard dose, which is more effective than the 5 mg dose (71% vs 62% pain relief at 2 hours) 5, 6
• Maximum dose is 30 mg per day 1
• Limit use to no more than 2 days per week to prevent medication overuse headache 1

Critical Safety Considerations

Contraindications to Rizatriptan

• Avoid in patients with uncontrolled hypertension or coronary artery disease 1
• Do not use concurrently with ergot-type medications or other triptans 1
• Contraindicated in pregnancy and those with ischemic vascular conditions 4

Medication Overuse Headache Risk

• Monitor for medication overuse headache if either medication is used more than twice weekly (≥10 days per month for triptans) 4, 1
• If acute medications are needed more frequently than 8 days per month, initiate preventive therapy with propranolol, topiramate, or CGRP monoclonal antibodies 1

When This Strategy Fails

Next Steps After Dual Failure

• If rizatriptan also fails after adequate trial (2-3 headache episodes), try a different triptan (almotriptan, eletriptan, frovatriptan, naratriptan, sumatriptan, or zolmitriptan) as patients may respond differently to various triptans 4
• Consider combining a triptan with an NSAID or acetaminophen for enhanced efficacy 4
• Reserve lasmiditan for patients who fail all other pharmacologic treatments in this guideline 4