What is the recommended dosing schedule for Nurtec (rimegepant) for migraine prophylaxis in an adult patient with a history of episodic migraines?

Nurtec (Rimegepant) Dosing for Migraine Prophylaxis

For migraine prevention, take Nurtec ODT 75 mg orally every other day (every other calendar day), regardless of whether you have a migraine that day. 1

Dosing Schedule

• Standard preventive dose: 75 mg every other day 1
• Maximum frequency: Do not take doses on consecutive days for prevention 1
• Duration: Long-term use up to 52 weeks has been studied and shown sustained efficacy without diminishing effect 2

Administration Instructions

• Use dry hands to peel back the foil covering of one blister 1
• Remove the orally disintegrating tablet (ODT) gently—do not push through the foil 1
• Place the tablet on your tongue or under your tongue immediately after opening 1
• The tablet will dissolve in saliva and can be swallowed without water 1
• Do not store the tablet outside the blister pack 1

Combining Prevention with Acute Treatment

You can use rimegepant for both prevention AND acute treatment on the same medication. 1, 2

• On your scheduled "every other day" dosing days, take your 75 mg dose as planned 1
• On non-scheduled days, if you develop a migraine, you may take one additional 75 mg tablet as needed for acute treatment 1, 2
• Critical limit: Do not exceed 18 doses in any 30-day period 1
• This dual-use approach (every other day scheduled + as-needed on off days) was studied for 52 weeks and found safe and effective 2

Important Drug Interactions

Avoid or adjust dosing with these medications: 1

• Strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, clarithromycin): Avoid concomitant use entirely 1
• Moderate CYP3A4 inhibitors (e.g., erythromycin, fluconazole, diltiazem): Avoid taking another dose of rimegepant within 48 hours 1
• Strong or moderate CYP3A inducers (e.g., rifampin, phenytoin, carbamazepine): Avoid concomitant use as these reduce rimegepant effectiveness 1
• Potent P-glycoprotein inhibitors (e.g., cyclosporine, quinidine): Avoid another dose within 48 hours 1

Evidence Quality and Guideline Context

The 2024 VA/DoD guidelines note insufficient evidence to make a firm recommendation for or against rimegepant for migraine prevention, though they acknowledge its efficacy for acute treatment. 3 However, the FDA approval is based on a phase 2/3 randomized controlled trial showing rimegepant reduced monthly migraine days by 0.8 days more than placebo (4.3 vs 3.5 days reduction, p=0.0099). 4

The 2025 American College of Physicians guidelines focus exclusively on acute migraine treatment and do not address preventive therapy, positioning rimegepant as a third-line acute option after triptan-NSAID combinations fail. 3

Safety Profile

• Adverse events occurred in 36% of patients on rimegepant versus 36% on placebo in the preventive trial 4
• Most common side effects in long-term use: upper respiratory tract infection (8.8%), nasopharyngitis (6.8%), sinusitis (5.1%) 5
• Discontinuation due to adverse events was uncommon (2.8% in 52-week study) 2
• No signal of hepatotoxicity or medication overuse headache was identified in long-term studies 2, 5
• Hypersensitivity reactions (including dyspnea and rash) can occur, sometimes days after administration—discontinue if this occurs 1

Common Pitfalls to Avoid

• Do not use rimegepant daily for prevention—the approved schedule is every other day only 1
• Do not exceed 18 doses in 30 days when combining preventive and acute use 1
• Do not assume this replaces first-line preventive agents—stronger guideline support exists for candesartan, telmisartan, erenumab, fremanezumab, and galcanezumab for episodic migraine prevention 3
• Do not use in patients with prior hypersensitivity to rimegepant 1