52 yo F with a 36 year history of migraine. Has had good control with topiramate 100 mg daily and as needed treatment for breakthrough attacks with rizatriptan 10 mg. Recently diagnosed (in past month) with stable coronary artery disease. Cardiology recommends discontinuing the rizatriptan. She only needs to use the rizatriptan around 3 times per year a long as she is on her daily topiramate. What does the audience suggest I use to replace the rizatriptan for acute breakthrough that has no risk of coronary vasospasm? She has HMO type insurance with many restrictions.
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Huma Sheikh, CEO, NY Neurology Medicine, PCApril 01, 2021I agree with the above, a triptan may still be a viable option. The other suggestions above also make good sense, I tend to stay away from lasmitidan as well for now.
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Heidi Schwarz, Professor of Clinical Neurology, URMCMarch 28, 2021I will start by saying that I am not sure she cannot continue with rizatriptan given her infrequent use and assuming she has no symptoms when using it. There has been little data to clearly link a coronary event with the use of a triptan. However, if an alternative is tried, I would recommend a combination of an antiemetic (even if she does not have nausea) and an NSAID. I tend to use prochlorperazine and diclofenac but metoclopramide and other NSAIDs are clearly an option. If this does not work, I think you do have reason to request either Nurtec or Ubrelvy from her insurer which appear to be quite safe with known CAD. I steer away from lasmitidan given the side effect issues.