Migraine Management with Nurtec and Maxalt

Clinical Approach to Using Both Medications

The American College of Physicians recommends using rizatriptan (Maxalt) as first-line acute therapy for migraine attacks, with strong evidence supporting its efficacy, and rimegepant (Nurtec) as an alternative for acute treatment if triptans are contraindicated or poorly tolerated, with a weaker recommendation strength 1, 2
The American Academy of Family Physicians suggests limiting rizatriptan to no more than 2 days per week to prevent medication overuse headache, with a maximum dose of 30 mg per day 3, 4, 5
The Department of Veterans Affairs and Department of Defense guidelines recommend using rimegepant for prevention and rizatriptan for acute rescue, with no pharmacologic contraindication to having both medications available to the same patient 1, 2

The American Heart Association recommends avoiding the use of rizatriptan in patients with uncontrolled hypertension or coronary artery disease, and concurrent use with ergot-type medications or other triptans 3, 4
The American Academy of Neurology suggests monitoring for medication overuse headache if either medication is used more than twice weekly, and initiating preventive therapy with first-line options including propranolol, topiramate, or CGRP monoclonal antibodies if acute medications are needed more frequently 4, 5

For patients with migraines occurring ≤8 days per month, the American Academy of Family Physicians recommends using rizatriptan 10 mg as needed for acute attacks, with a limit of 2 days per week 3
For patients with migraines occurring >8 days per month, the American College of Physicians suggests starting rimegepant 75 mg every other day for prevention, with rizatriptan 10 mg available for breakthrough attacks 1