Migraine Treatment with Maxalt After Failed Nurtec
Evidence-Based Rationale
- The Department of Veterans Affairs and Department of Defense guidelines state there is no pharmacologic contraindication to having both rimegepant (Nurtec) and rizatriptan (Maxalt) available to the same patient 1
- The American College of Physicians recommends rizatriptan as first-line acute therapy with strong evidence, while rimegepant is suggested as an alternative when triptans are contraindicated or poorly tolerated 1
- The 2024 VA/DoD guidelines provide strong recommendations for rizatriptan and weak recommendations for ubrogepant for short-term migraine treatment, suggesting rizatriptan as the more robust option 2, 3
Practical Implementation
- Rizatriptan reaches peak blood concentration in 60-90 minutes and shows onset of effect as early as 30 minutes after dosing 4
- Waiting one hour after failed ubrogepant is reasonable, though no specific waiting period is mandated by guidelines 1
- The standard dose of rizatriptan is 10 mg, which is more effective than the 5 mg dose (71% vs 62% pain relief at 2 hours) 1
- The maximum dose of rizatriptan is 30 mg per day, and use should be limited to no more than 2 days per week to prevent medication overuse headache 1
Critical Safety Considerations
- Rizatriptan is contraindicated in patients with uncontrolled hypertension or coronary artery disease 1
- Rizatriptan should not be used concurrently with ergot-type medications or other triptans 1
- Rizatriptan is contraindicated in pregnancy and those with ischemic vascular conditions 4
- Monitor for medication overuse headache if either medication is used more than twice weekly (≥10 days per month for triptans) 5, 1
When This Strategy Fails
- If rizatriptan also fails after adequate trial (2-3 headache episodes), try a different triptan (almotriptan, eletriptan, frovatriptan, naratriptan, sumatriptan, or zolmitriptan) as patients may respond differently to various triptans 4, 5
- Consider combining a triptan with an NSAID or acetaminophen for enhanced efficacy 5
- Reserve lasmiditan for patients who fail all other pharmacologic treatments in this guideline 5