Nurtec (Rimegepant) for Pediatric Migraine
Nurtec (rimegepant) is NOT currently recommended for pediatric patients with migraine, as there is insufficient evidence for its safety and efficacy in children and adolescents, and current guidelines do not include it in pediatric treatment algorithms. 1, 2
Current Pediatric Migraine Treatment Recommendations
First-Line Acute Treatment
- Ibuprofen is the recommended first-line acute therapy for children and adolescents with migraine, dosed appropriately for body weight 1, 2
- Bed rest alone may suffice for children with short-duration attacks 1, 2
- Acetaminophen can be used as an alternative if NSAIDs are contraindicated 2
Second-Line Acute Treatment for Adolescents (Ages 12-17)
- Triptans should be considered for adolescents who have inadequate response to NSAIDs 1, 2
- Nasal spray formulations of sumatriptan and zolmitriptan are the most effective triptan options in this age group 1, 2
- Rizatriptan orally disintegrating tablets (ODT) and almotriptan oral are also options 2
- If one triptan is ineffective, trying another triptan or an NSAID-triptan combination may be beneficial 2
Preventive Treatment Options
- Propranolol, amitriptyline, and topiramate are used in practice for preventive treatment, though their effectiveness has not been proven in pediatric clinical trials 1
- Amitriptyline combined with cognitive behavioral therapy may be effective 2
Why Rimegepant Is Not Recommended for Pediatrics
Lack of Pediatric Evidence
- All clinical trials of rimegepant have been conducted exclusively in adults aged ≥18 years 3, 4, 5
- The pivotal studies demonstrating rimegepant's efficacy for acute and preventive migraine treatment specifically enrolled only adult participants 6, 5
- No pediatric safety or efficacy data exists for rimegepant 7
Adult-Only Guidelines
- The 2024 VA/DoD guidelines and 2025 American College of Physicians guidelines that include rimegepant recommendations apply only to adult outpatient populations 1
- These guidelines suggest rimegepant for short-term treatment of migraine in adults with a "weak for" recommendation 1
- The American College of Physicians considers rimegepant as an option only for nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID 1
Current Research Landscape
- Recent reviews acknowledge that treatments for debilitating migraine in children often lack FDA approval or evidence of efficacy for pediatric populations 7
- Ongoing studies are needed to assess newer treatments like CGRP antagonists in the pediatric setting 7
Important Clinical Caveats
Medication Overuse Headache Risk
- Monitor for medication overuse headache in pediatric patients: NSAIDs ≥15 days/month and triptans ≥10 days/month 2
- This threshold applies to currently approved pediatric medications and would theoretically apply to any future use of rimegepant
Avoid Harmful Medications
- Never use opioids or butalbital for pediatric migraine treatment, as they lead to dependency and rebound headaches 2