Can Someone Be on Nurtec and Sumatriptan?
Yes, a patient can have both Nurtec ODT (rimegepant) and sumatriptan available for migraine treatment, and there is no pharmacologic contraindication to using both medications in the same patient. 1
Key Safety Parameters
You can use both medications, but NOT within 24 hours of each other. 2 The FDA label for sumatriptan explicitly contraindicates taking sumatriptan within 24 hours of another triptan or ergot-containing medication, and while rimegepant is not a triptan, clinical practice guidelines recommend maintaining this separation window. 1, 2
Clinical Implementation Strategy
When to Use Each Medication
Use rimegepant (Nurtec ODT) as first-line for patients with cardiovascular contraindications to triptans, including uncontrolled hypertension, coronary artery disease, cerebrovascular disease, or peripheral vascular disease, as rimegepant does not cause vasoconstriction. 3, 4
Use sumatriptan for breakthrough treatment when rimegepant fails after adequate trial (waiting at least 1 hour), as there is no pharmacologic contraindication to having both available. 1
Sumatriptan should be reserved for patients without ischemic vascular conditions, uncontrolled hypertension, or significant cardiovascular disease. 2
Practical Dosing Algorithm
If rimegepant 75 mg ODT is taken first and fails to provide relief after 1 hour, sumatriptan can be administered (oral 50-100 mg or subcutaneous 6 mg). 1
Wait at least 2 hours between taking rimegepant and sumatriptan to allow adequate time to assess rimegepant's efficacy. 1
Do not take another dose of either medication within 24 hours of taking sumatriptan. 2
If sumatriptan is taken first, wait a full 24 hours before taking rimegepant. 2
Critical Medication Overuse Prevention
Limit total use of both medications combined to no more than 2 days per week (10 days per month) to prevent medication-overuse headache. 5, 1 This frequency limit applies to the cumulative use of all acute migraine medications, not each medication individually.
Drug Interaction Considerations
Avoid rimegepant with strong CYP3A4 inhibitors (ketoconazole, itraconazole, clarithromycin), as this significantly increases rimegepant exposure. 3
Avoid another dose of rimegepant within 48 hours when used with moderate CYP3A4 inhibitors or potent P-glycoprotein inhibitors. 3
Sumatriptan has no significant interactions with CYP3A4 inhibitors, making it a safer choice when patients are on these medications. 2
Absolute Contraindications for Sumatriptan
- Ischemic heart disease or history of myocardial infarction 2
- Coronary artery vasospasm or Prinzmetal's angina 2
- Uncontrolled hypertension 2
- Cerebrovascular disease, stroke, or TIA 2
- Peripheral vascular disease 2
- Hemiplegic or basilar migraine 2
- Severe liver problems 2
When This Strategy Fails
If both medications fail after adequate trials (2-3 headache episodes each), try a different triptan (rizatriptan, eletriptan, zolmitriptan) as failure of one triptan does not predict failure of others. 1, 6
Consider combination therapy with triptan plus NSAID (naproxen 500 mg or ibuprofen 400-800 mg) for enhanced efficacy. 5
Initiate preventive therapy immediately if requiring acute treatment more than twice weekly, as this pattern leads to medication-overuse headache and treatment failure. 5, 1