What is the recommended dosing of Nurtec (rimegepant) for a patient with a history of migraine attacks?

Nurtec (Rimegepant) Dosing

For acute migraine treatment, take rimegepant 75 mg orally as a single dose at migraine onset, with a maximum of one dose per 24 hours and no more than 18 doses per 30 days; for preventive treatment, take 75 mg every other day. 1

Acute Treatment Dosing

• The FDA-approved dose is 75 mg taken orally as needed when a migraine attack begins 1
• The maximum dose in any 24-hour period is 75 mg (one tablet only) 1
• Limit use to no more than 18 doses in a 30-day period, as safety beyond this frequency has not been established 1
• Take the orally disintegrating tablet (ODT) immediately after opening the blister pack by placing it on or under the tongue, where it will dissolve without additional liquid 1

Preventive Treatment Dosing

• For episodic migraine prevention, take 75 mg every other day on a scheduled basis 1
• This preventive dosing regimen is distinct from acute treatment and follows a regular schedule rather than as-needed use 1

Place in Therapy Algorithm

• Rimegepant should be considered third-line for acute migraine, reserved for patients who have failed or cannot tolerate combination therapy with a triptan plus NSAID 2
• The American College of Physicians found that CGRP antagonists like rimegepant may have lower likelihood of pain freedom at 2 hours compared to triptan plus NSAID combination therapy 2
• Rimegepant is particularly valuable for patients with documented triptan unsuitability due to intolerance, lack of efficacy after trying ≥2 triptans, or cardiovascular contraindications to triptans 3
• In a phase 4 trial of triptan-unsuitable adults, rimegepant achieved 55.9% pain relief at 2 hours versus 32.7% with placebo 3

Critical Drug Interactions Requiring Dose Adjustment

• Avoid concomitant use with strong CYP3A4 inhibitors entirely 1
• When taking moderate CYP3A4 inhibitors, avoid another dose of rimegepant within 48 hours 1
• Avoid concomitant use with strong or moderate CYP3A inducers, as they may lead to loss of efficacy 1
• When taking potent P-glycoprotein inhibitors, avoid another dose within 48 hours 1

Medication-Overuse Headache Prevention

• Strictly limit all acute migraine medications, including rimegepant, to no more than 2 days per week to prevent medication-overuse headache 4, 2
• The threshold for medication-overuse headache with gepants has not been definitively established, but caution is warranted with frequent use 2
• If requiring acute treatment more than twice weekly, initiate preventive therapy immediately 4

Safety Profile and Tolerability

• Long-term safety data from 1800 participants using rimegepant for up to 52 weeks showed the most common adverse events were upper respiratory tract infection (8.8%), nasopharyngitis (6.8%), and sinusitis (5.1%), with most being mild or moderate 5
• No signal of hepatotoxicity, drug abuse potential, or medication-overuse headache was identified in long-term studies 5
• Hypersensitivity reactions, including dyspnea and rash, can occur days after administration; if this occurs, discontinue rimegepant immediately 1
• Rimegepant is contraindicated in patients with a history of hypersensitivity to rimegepant or any of its components 1

Common Pitfall to Avoid

• Do not use rimegepant as first-line therapy for typical migraine attacks—NSAIDs or triptan plus NSAID combinations should be tried first unless contraindicated 4, 2
• Do not exceed the maximum frequency limits, as the safety of using more than 18 doses in 30 days has not been established 1