Primary Care Migraine
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Use in Adults
Gepants

​THIS GUIDE PROVIDES A PARTIAL LISTING OF PRESCRIBING INFORMATION FOR THIS MEDICATION. FOR A FULL LISTING OF PRESCRIBING INFORMATION PLEASE REFER TO THE PACKAGE INSERT. CLICK ON THE BRAND NAME® TO VIEW THE LINK TO THE PACKAGE INSERT.
Rimegepant (Nurtec®) Click Here to Expand
Brands:
  • Nurtec® ODT (rimegepant sulfate) For more complete prescribing information click here for PACKAGE INSERT
Initial Dose:
  • 75 mg
​Dose Schedule: 
  • 75 mg under the tongue at onset of migraine as needed for the treatment of an acute migraine attack 
​Max Daily Dose:
  • 75 mg
Side Effects:
  • Nausea, abdominal pain, indigestion
Headache Specialist Comments: 
  • The main advantages of the gepants are their good efficacy & tolerability and minimal to no risk for medication overuse headache.  Also, they do not have a cardiovascular contraindication like the triptans.
  • There is no evidence from clinical studies that gepants are more efficacious than triptans, ditans or ergots.
  • The main disadvantages are their expense and need for a prior authorization in many cases. 
  • Patients may need to “try and fail” 1-2 triptans before insurance approval.
  • Consider their use as primary treatment of the migraine attack in following situations:
    • Patients whose triptan does not provide adequate pain relief at 2 hours
    • Patients who are intolerant of triptans
    • Patients who have medication overuse headache (e.g., those that using acute medications ≥ 10 days per month)
    • Patients in whom triptans are contraindicated, particularly for patients with cardiovascular contraindications, since the gepants do not have a cardiovascular contraindication. ​
Precautions and Risk:
  • Hypersensitivity reactions
Contraindications:
  • Avoid in those taking strong CYP3A4 inhibitors (see Drug Interactions)
Pregnancy and Breast-Feeding
  • Click Nurtec® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
Common Drug Interactions:
  • Strong CYP3A4 Inhibitors: may increase serum levels of rimegepant.  Consider avoidance if taking these medications:  clarithromycin, protease inhibitors and antifungals (e.g., itraconazole and ketoconazole) among others.
  • Moderate CYP3A4 Inhibitors: Avoid another dose within 48 hours when administered with a moderate CYP3A4 inhibitor. These drugs include verapamil, erythromycin, diltiazem, amiodarone, among others.
  • Strong and moderate CYP3A Inducers: May decrease serum concentration of rimegepant. These include carbamazepine, phenytoin, phenobarbital, St. John’s wort and others.
  • Inhibitors of P-gp or BCRP: Avoid concomitant administration. Consider avoidance if taking these medications:  amiodarone, clarithromycin, cyclosporin, colchicine, diltiazem, erythromycin, felodipine, ketoconazole, lansoprazole, omeprazole and others.
Counseling Tips:
  • Keep the tablet in the blister/outer aluminum pouch until ready to use
  • Allow tablet to disintegrate on or under the tongue
  • Take early in the attack when the pain is mild
Ubrogepant (Ubrelvy®) Click Here to Expand
​Brands:
  • Ubrelvy® (ubrogepant) For more complete prescribing information click here for PACKAGE INSERT
Initial Dose:
  • 50 mg
​Dose Schedule:  
  • 50 mg by mouth at onset of migraine as needed for the treatment of an acute migraine attack; may repeat dosage in two hours, if not pain free or with adequate relief
  • 100 mg tablet can be used as the initial dosage if the 50 mg dosage does not provide pain freedom or adequate pain relief 
​Max Daily Dose:
  • 200 mg
Side Effects:
  • Nausea and somnolence
Headache Specialist Comments:
  • The main advantages of the gepants are their good efficacy & tolerability and minimal to no risk for medication overuse headache.  Also, they do not have a cardiovascular contraindication like the triptans.
  • There is no evidence from clinical studies that gepants are more efficacious than triptans, ditans or ergots.
  • The main disadvantages are their expense and the requirement for prior authorization.  
  • Patients may need to “try and fail” 1-2 triptans before insurance approval.
  • Consider their use as primary treatment of the migraine attack in following situations:
    • Patients whose triptan does not provide adequate pain relief at 2 hours
    • Patients who are intolerant of triptans
    • Patients who have medication overuse headache (e.g., those who are using acute medications ≥ 10 days per month)
    • Patients where triptans are contraindicated, particularly for patients with cardiovascular contraindications, since the gepants do not have a cardiovascular contraindication. ​
Precautions and Risk:
  • Avoid in patients with end stage renal disease
  • Hypersensitivity reactions
Contraindications:
  • Avoid in those taking strong CYP3A4 inhibitors (see Drug Interactions)
Pregnancy and Breast-Feeding:
  • Click Ubrelvy® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
Common Drug Interactions:
  • Strong CYP3A4 Inhibitors: may increase serum levels of rimegepant.  Consider avoidance if taking these medications. These include clarithromycin, protease inhibitors and antifungals (e.g., itraconazole and ketoconazole) and others.
  • Moderate CYP3A4 Inhibitors: Avoid another dose within 48 hours when administered with a moderate CYP3A4 inhibitor. These drugs include verapamil, erythromycin, diltiazem, amiodarone and others.
  • Strong and moderate CYP3A Inducers: May decrease serum concentration of rimegepant. These medications include carbamazepine, phenytoin, phenobarbital, St. John’s wort and others.
  • Inhibitors of P-gp or BCRP: Avoid concomitant administration.  These medications include amiodarone, clarithromycin, cyclosporin, , colchicine, diltiazem, erythromycin, felodipine, ketoconazole, lansoprazole, omeprazole and others.
​ Counseling Tips:  
  • Take early in the attack when the pain is mild
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For Technical Support
  • Home
  • Education
    • CME Modules >
      • Module 1: Diagnose Migraine
      • Module 2: Secondary Headache
      • Module 3: Acute Therapy
      • Module 4: Preventive Therapy
    • Non-CME Modules >
      • Diagnose Migraine
      • Secondary Headache
      • Acute Therapy
      • Prevention
  • Diagnosis Tool
  • Med Guides
    • Acute Treatment Guide >
      • NSAIDs
      • Triptans
      • Gepants
      • Ditans
      • Combinations
      • Ergotamines
    • Preventive Guide >
      • Antidepressants
      • Antihypertensives
      • Antiepileptics
      • CGRP Monoclonal Antibodies
      • OnabotulinumtoxinA
      • CGRP Antagonists - Oral
    • Med-Guide
  • Infographics
    • Diagnose Migraine
    • ABCs of Migraine Management
    • Acute Migraine
    • Prevent Migraine