Rimegepant for Acute Migraine Treatment

Place in Therapy Algorithm

The American Academy of Neurology recommends starting with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) for mild to moderate migraine attacks 1, 3
For moderate to severe attacks, the American Headache Society suggests using combination therapy: triptan (sumatriptan 50-100 mg) PLUS NSAID (naproxen 500 mg), which is superior to either agent alone 2, 3
The American College of Physicians recommends trying different triptans if one fails—failure of one triptan does not predict failure of others 1
Consider subcutaneous sumatriptan 6 mg for rapid progression to peak intensity or significant vomiting, as suggested by the American Academy of Neurology 1, 3
Use rimegepant 75 mg ODT when all available triptans have failed after adequate trial (no or insufficient response in at least 3 consecutive attacks) OR when triptans are contraindicated, as recommended by the American Headache Society 1, 2, 4

Pain freedom at 2 hours: 19.6% with rimegepant vs 12.0% with placebo (number needed to treat = 13), according to the American College of Physicians 2
Freedom from most bothersome symptom at 2 hours: statistically superior to placebo, as reported by the American Academy of Neurology 2

Limit rimegepant to no more than 2 days per week for acute treatment to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches, as recommended by the American Headache Society 1, 2, 3
If requiring acute treatment more than twice weekly, initiate preventive therapy immediately, according to the American College of Physicians 3

No cardiovascular contraindications—unlike triptans, rimegepant can be used in patients with ischemic heart disease, uncontrolled hypertension, or significant cardiovascular disease, as noted by the American Academy of Neurology 1
Rimegepant is more expensive than first-line treatments (NSAIDs and triptans), according to the American College of Physicians 4
Insurance coverage may require documentation of triptan failure or contraindication, as reported by the American Headache Society 4

Do not use rimegepant as first-line therapy—always try NSAIDs and triptans first unless contraindicated, as recommended by the American Academy of Neurology 1, 2, 4
Do not allow frequent use pattern to develop—transition to preventive therapy if needed more than twice weekly, according to the American College of Physicians 3