Nurtec ODT Explained: Usage, Dosage, And Side Effects
If you have ever experienced having a migraine in your life, then you — together with 35 million other Americans — understand exactly how debilitating this disease can be. The American Migraine Foundation states that migraines are three times more common in women, but they can happen to anyone regardless of their age, gender, or race. While migraines have been observed to run in families, the reason why it happens still has yet to be fully established.
People who experience migraines are sometimes able to pinpoint certain things that can trigger their episodes, especially those who have them frequently. Triggers can vary from person to person, but common ones include certain types of food (e.g., alcohol, chocolate, nitrates), caffeine, emotional stress, flashing lights, sunlight, pressure changes in the atmosphere, strong odors, loud noises, and disturbances in sleep patterns.
The headache that occurs during a migraine attack is often described as throbbing, pulsating, or pounding. It can last for hours, sometimes even days. It can be associated with sensitivity to lights, sounds, or smells, as well as nausea and/or vomiting. It can be felt on one or both sides of the head, front or back. It may even extend to the area surrounding the eyes or cheeks. People who have migraines will often be in so much pain that they are unable to do their usual daily activities.
Fortunately, there are several options available to treat (and even prevent) migraine episodes. One type of medication that can do both is Nurtec ODT.
What is Nurtec?
Nurtec is the brand name for a drug called rimegepant, a calcitonin gene-related peptide (CGRP) receptor blocker created by Biohaven Pharmaceutical Holding Company Ltd, a company recently acquired by Pfizer. Nurtec was initially approved by the U.S. Food & Drug Administration (FDA) early in 2020, and has since been prescribed over 2 million times for Americans with migraines.
As an orally disintegrating tablet (ODT), Nurtec is taken by placing the tablet on or under your tongue and letting it dissolve on its own. According to the American Pharmaceutical Review, ODTs have several advantages compared to other forms of oral medications. Not only are ODTs ideal for people who have trouble swallowing (e.g., children, people with Parkinson's disease, people who have undergone bariatric surgery), but they are also absorbed by the body fairly quickly, which means that they are fast-acting. They also avoid getting processed in the liver, which may reduce the risk of certain side effects.
The dose of Nurtec is limited to 75 milligrams. It can be taken once a day as needed to treat an acute migraine attack, but it can also be taken every other day to prevent episodic migraine. Because it dissolves quickly with saliva, there is no need to take it with water. According to GoodRx, it can get rid of an acute migraine attack within a couple of hours, and you may notice a reduction in the frequency of your migraine attacks if you consistently take it preventively for at least a couple of months.
How Nurtec works
The calcitonin gene-related peptide (CGRP) is a sequence of proteins that is mostly found in Aδ (A-delta) and C sensory nerve fibers. Aδ fibers transmit touch, pressure, pain, and cold sensations, while C fibers transmit pain and warm sensations. According to a 2014 article in Physiological Reviews, this pain-sensing property of CGRP is one of the main reasons why inhibitors of CGRP receptors such as Nurtec are effective in alleviating pain caused by migraines.
Per the Handbook of Experimental Pharmacology, CGRPs have also been shown to cause dilation of blood vessels, which possibly play a role in the mechanism of migraine attacks as well. To this day, however, there is much debate regarding this, and the more accepted theory is that migraines occur as a combination of many factors. The FDA explains that people who experience migraines most likely have some form of dysfunction in their brainstem. Upon exposure to a migraine trigger, the brain reacts by excessively dilating its blood vessels. This activates pain fibers located in the walls of the vessels, which causes nerves to release CGRP. CGRP further dilates blood vessels, leading to inflammation and release of toxic and chemical substances.
As a CGRP receptor inhibitor, Nurtec competes with CGRP by binding to its receptors and preventing it from exerting its migraine-inducing effects. These include inhibiting pain signals, preventing dilation of blood vessels without causing them to narrow, and inhibiting inflammation. It is able to exert these effects even with just one dose.
Who are eligible to take Nurtec?
The FDA has approved Nurtec only for use in the treatment of acute migraine attacks (with or without aura) in adults, and in the prevention of episodic migraine in adults.
According to the American Academy of Family Physicians (AAFP), migraines can be classified as migraine without aura, migraine with aura, chronic migraine, episodic migraine, and medication-overuse headache. To be diagnosed with migraine without aura, a person should have had at least five migraine attacks lasting 4 to 72 hours; associated with nausea, vomiting, light sensitivity, or sound sensitivity; and with at least two of the following characteristics: worsened by (or causes avoidance of) normal physical activities, pulsating in nature, moderate or severe in pain intensity, and one-sided in location.
On the other hand, WebMD explains that migraines with aura are typically described as migraine episodes with additional symptoms that can occur up to an hour before (or during) migraine attacks. These symptoms include vision abnormalities (e.g., blind spots, tunnel vision, seeing sparkles or stars, light flashes), confusion, weakness, involuntary jerks, hearing noises in your head, speech difficulties, and pins and needles.
People with episodic migraine experience headaches for 0 to 14 days each month, while people with chronic migraine have headaches at least 15 days a month for at least 3 months. People with medication-overuse headaches are the ones who already have a pre-existing headache condition, but continue to have headaches at least 15 days a month because of regularly taking too much headache medication.
Nurtec side effects
Nurtec is a fairly new drug, so there is still much to learn about it, including possible side effects. Currently, data on the known side effects of Nurtec have all come from clinical trials, and these include nausea, indigestion, and abdominal pain.
According to Medical News Today, nausea was the most common side effect observed in people who took Nurtec during its clinical trials. It may be difficult to determine if this is due to the drug or something else, because many things can cause nausea, including migraine itself. If you are experiencing nausea from Nurtec, speak with your doctor first before taking any other medications or supplements to avoid any unwanted drug interactions. If it helps, try drinking clear liquids or cold drinks, staying away from greasy food, eating and drinking more slowly, and avoiding too much movement right after eating (via Cleveland Clinic). Indigestion and abdominal pain occurred in about 2% of the participants of the trials. If this happens to you, SingleCare suggests taking Nurtec together with food. You can also try over-the-counter antacids, but ask your doctor or pharmacist first before you do.
Although rare, allergic reactions have also been reported with the use of Nurtec. The severity of these reactions can range from mild to fatal, and include symptoms like rash, itching, shortness of breath, and swelling of your face, tongue, lips, hands, and/or feet. If this happens, get medical help right away by calling 911 or going to the nearest emergency room in your area (per Drugs.com).
What to take note of before taking Nurtec
Before your doctor prescribes Nurtec for you, there are a few things that they need to review about your medical history to ensure that it is a safe drug for you to take. According to Healthline, if you have any underlying severe impairment in your liver or kidneys (e.g., cirrhosis, end-stage kidney failure), your doctor will most likely avoid giving you Nurtec, as these conditions can impair your body's ability to process and properly eliminate the drug. Similarly, if you have had a previous allergic reaction to Nurtec or a known allergy to any of its ingredients, your doctor may opt to prescribe you with a different type of migraine medication.
Per Drugs.com, it is not known whether drinking alcohol has any effect on Nurtec, but it is best to avoid it as much as possible to be on the safe side. It is also unclear whether it is safe to take Nurtec during pregnancy. According to the FDA, data on pregnant women is inadequate, although animal studies show that taking high concentrations of Nurtec during the stages of organ development led to low body weight and greater fetal variations in rats. In addition, there is no data available regarding the effect of taking Nurtec while breastfeeding, and therefore should be avoided unless its benefits clearly outweigh the possible risks. Also, children should not be given Nurtec, because its safety and efficacy for that population has not yet been established.
Medications and other substances that may interact with Nurtec
Nurtec should not be combined with substances that can induce or inhibit CYP3A4. As explained by a 2008 article published in the Current Drug Metabolism journal, CYP3A4 (aka cytochrome P450 3A4) is one of the major enzymes in the liver and intestines that metabolizes up to 50% of drugs that we take. Substances that get processed through these enzymes can be classified as substrates, inducers, or inhibitors. CYP3A4 inducers (e.g., barbiturates, steroids, phenytoin) promote metabolism, and can therefore decrease the efficacy of drugs that get metabolized by CYP3A4. In contrast, inhibitors (e.g., grapefruit juice, ciprofloxacin, fluconazole) prevent metabolism, which can lead to increased toxicity. Nurtec is a weak CYP3A4 inhibitor, so its concentration in the body can be affected by the presence of moderate or strong CYP3A4 inducers and inhibitors (via RxList).
According to a 2020 review published in Pharmaceutics, Nurtec is also a substrate of P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP) — both of which are also involved in the metabolism of Nurtec. Therefore, taking Nurtec with medications that are P-gp or BCRP inhibitors can increase its toxicity. P-gp inhibitors include verapamil, nifedipine, indinavir, reserpine, mifepristone, clotrimazole, and digoxin. Meanwhile, examples of BCRP inhibitors include quercetin, novobiocin, estrone, omeprazole, saquinavir, and cyclosporine.
Because there are many substances that can interact with Nurtec, let your doctor know about all of the drugs and supplements you are (or planning on) taking — especially the ones that were not prescribed by them.
Missing a dose (or taking too much) of Nurtec
Per the FDA, the proper way to take Nurtec is to first ensure that your hands are dry when you open the blister pack. When removing the tablet from its packaging, do not push it against the foil. Instead, peel back the foil and gently take it out. Only open the blister pack if you plan on taking the tablet, and do not transfer the tablet to a different container, including pill boxes.
There is not much data on what can happen if you miss a dose of Nurtec or take too much of it. According to Healthline, if you are taking Nurtec to prevent episodic migraine and you forgot your regular dose, take it as soon as you can, but do not double up your dose. Adjust your schedule accordingly so that you take it every other day, starting from the day when you last remembered to take the drug. If you are unsure, consult with your doctor or pharmacist.
If you accidentally or intentionally took more Nurtec tablets than prescribed, contact your doctor immediately or call the National Poison Control Center at 1-800-222-1222. But if you are experiencing severe symptoms, seek medical help right away by calling 911 or going to the nearest emergency room. Nurtec is only intended to be used once a day, every other day, for a maximum of 18 days in a one-month period. There is no data on what may happen if you take it more often than that.
Medications similar to Nurtec
According to Migraine.com, there are two main types of CGRP receptor inhibitors: "gepants" and monoclonal antibodies. Nurtec, also known as rimegepant, is one of the gepant CGRP blockers that bind to its receptor and prevent it from causing its downstream effects. There are other drugs under the gepants as well, including atogepant (Quilipta), ubrogepant (Ubrelvy), and zavegepant (ZAVZPRET).
Quilipta is used to prevent episodic and chronic migraines, while Ubrelvy is for treating acute migraines with or without aura. Nurtec is indicated for all of these except for preventing chronic migraines. Unlike Nurtec, Quilipta and Ubrelvy are tablets that need to be swallowed.
Individual clinical trial results show that more people experienced pain relief from Nurtec, but more people were relieved of their most bothersome symptoms (e.g., sensitivity to light or sound, nausea) when they took Ubrelvy. In addition, people who took Quilipta had a greater decrease in their monthly migraine days, compared to those in the Nurtec clinical trial. Notable side effects of Ubrelvy and Quilipta include nausea and fatigue. Ubrelvy can also cause dry mouth, and Quilipta can cause constipation and weight loss (via Drugs.com).
In March 2023, the FDA approved the first-ever CGRP inhibitor nasal spray called ZAVZPRET. Similar to Ubrelvy, it is used to treat acute episodes of migraine with or without aura. Pfizer estimates that ZAVZPRET will be available for purchase in July 2023. Possible side effects based on clinical trials include loss of taste, altered taste, nausea, vomiting, and nasal discomfort.
Other CGRP inhibitors
CGRP receptor blockers can also come in the form of monoclonal antibodies (mAbs), lab-made proteins that resemble the natural antibodies produced by our immune system (via Cleveland Clinic). Foreign substances contain specialized structures called antigens. Our body creates a unique antibody based off of the structure of an antigen. It is similar to a lock-and-key system, where only a certain key is able to fit in a specific lock.
There are currently four FDA-approved mAb CGRP inhibitors: erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), and eptinezumab (Vyepti). They are all used to prevent migraine episodes in adults (per WebMD). Aimovig, Ajovy, and Emgality come in injector pens or prefilled syringes that you can administer on your own, while Vyepti is given via infusion through a vein. They work by either blocking the CGRP receptor (similar to the gepants), or by binding to CGRP itself and preventing it from properly attaching to its receptor. Aimovig and Emgality are given once a month, Ajovy can be given once a month or once every 3 months, and Vyepti is given only once every 3 months.
A common side effect shared by Aimovig, Ajovy, and Emgality is injection site reactions, but all four of them have been shown to cause allergic reactions (e..g, rash, itching, swelling). In addition, Aimovig can cause constipation, and Vyepti can cause nasopharyngitis. There are no specific contraindications for the use of these medications aside from known serious allergic reactions to the drugs themselves or any of their ingredients.
Nurtec versus triptans
Triptans are medications that selectively block serotonin receptors. They are currently the first choice of treatment for acute migraine episodes with or without aura. Examples of triptans include sumatriptan, almotriptan, and zolmitriptan. Each of the triptans have additional indications, including treatment of cluster headaches, preventing migraine caused by menstruation, and treatment of migraine episodes in children and adolescents. They are available in many forms, including orally disintegrating tablets (ODTs), oral tablets, nasal sprays, and injections (per StatPearls).
A 2021 meta-analysis in Clinical Drug Investigation showed that triptans are more effective at relieving migraine pain compared to oral CGRP receptor inhibitors like Nurtec. However, according to the National Headache Foundation, triptans are not appropriate for use in people who have (or are at risk for) cardiovascular disease such as high blood pressure, high cholesterol, diabetes, stroke, heart attack, anginal chest pain, peripheral vascular disease, liver dysfunction, and kidney problems. In these cases, alternatives like Nurtec may be a good option. Triptans should also not be given to adults over 65 years old. Apart from sumatriptan, all other triptans are not safe for women who are pregnant and/or breastfeeding (via StatPearls).
According to the American Migraine Foundation, CGRP inhibitors have not been shown to interact with triptans, which means that it is relatively safe for people to be on both types of medications at the same time. However, you should still speak with your doctor if you are unsure of, or concerned with, any of your medications.
Nurtec versus lasmiditan
Lasmiditan (Reyvow) is a selective serotonin receptor agonist. It is a relatively new drug that acts on serotonin receptors — specifically, the ones that are located in nerves, not in blood vessels. This means that Reyvow is able to block pain signals that result in a headache, all while having no effect on blood vessels (per Harvard Health). It is FDA-approved for use in adults with acute episodes of migraine with or without aura. However, this drug is typically not prescribed to women who are (or are able to become) pregnant, because studies on animals show that it can cause decreased fetal body weight, birth defects, and fetal demise.
Reyvow is an oral tablet that should only be taken once a day, for a maximum of four times a month. Because it acts on the brain, it can cause dizziness and sedation. Because of this, it should not be combined with alcohol or any other substance that can depress the central nervous system. People who take Reyvow should also avoid driving or operating any kind of machinery for at least 8 hours after taking the drug.
Similar to Nurtec, Reyvow has the advantage of having fewer cardiovascular side effects, which makes it an ideal alternative to triptans (per Healio). According to Lilly, comparison of studies show that Reyvow at doses of 100 and 200 milligrams is more effective at relieving pain compared to Nurtec. Unlike Reyvow, however, Nurtec is not known to cause dizziness or sedation.
Other options for migraine treatment and prevention
Aside from those mentioned above, migraines can also be managed using a variety of other medications. Migraine treatment options include oral pain relievers (e.g., aspirin, ibuprofen), dihydroergotamine nasal sprays or injections, opioid tablets, antiemetics (e.g., metoclopramide, chlorpromazine), and intranasal lidocaine. Per the AAFP, combination medications are also common, including Excedrin (acetaminophen, aspirin, and caffeine) and Trexima (sumatriptan and naproxen). On the other hand, examples of medications that can be used to prevent migraines include antihypertensives (e.g., propranolol, metoprolol, verapamil), antidepressants (e.g., amitriptyline), anticonvulsants (e.g., valproate, topiramate), and botox injections (per Mayo Clinic).
Aside from medications, there are also devices that can help prevent or treat migraines without the use of drugs. Nerivio is a device that is placed around the upper arm, and works by activating sensory fibers, causing the nervous system to naturally release serotonin and norepinephrine. Cefaly is a device placed on the forehead; it works by stimulating the trigeminal nerve (which is believed to play a central role in the development of migraines) and desensitizing it over time. Lastly, gammaCore also uses electrical stimulation, but acts on the vagus nerve instead, one of the major nerves that regulates pain signals.
There are a lot of medications and devices available to treat migraines; which ones you take will all depend on what is safe and effective for you. Your doctor can help you through this process, and you can consult them if you have any questions or concerns regarding your medications.