Have a Migraine That Won’t Go Away with Medicine? New Options are Now Available

If you’re frustrated that your migraine won’t go away with medicine that your doctor recommends, stay hopeful. Research shows two oral calcitonin gene-related peptide (CGRP) inhibitors provide rapid relief from an acute Migraine attack in about 20% of patients.


The FDA has recently approved two new drugs in the ‘gepant’ category – Nurtec ODT (rimegepant) and Ubrelvy (ubrogepant), and they’ll be available this year.

Triptans are the most commonly used abortives now, but they are contraindicated for those with heart problems. Meds that target the CGRP peptide can prevent or treat Migraine without these cardiovascular side effects.

Some people find that triptans don’t help their Migraine attacks. For others, they’re less likely to reach for triptans to abort an attack due to side effects. The new acute medications approved come with far fewer side effects than triptans.

The FDA has now approved four preventative drugs that target CGRP:

Aimovig

Ajovy

Emgality

Vyepti

More recently, two acute medications that block CGRP have been approved:

CGRP is a neuropeptide involved in Migraine attacks, and researchers suspect blocking CGRP can effectively treat Migraine in some people.

New treatment options could address “unmet needs”

Dr. Richard Lipton, headache specialist and director of the Montefiore Headache Center in New York, explained the significance of new Migraine drugs on the horizon.


“Perhaps a third of people with Migraine don’t respond to triptans, 30% to 40% have recurrent attacks, and according to our estimate, 3.5 million people have absolute or relative contraindications for triptans among the 40 million people who get migraines,” Lipton said. “Clearly there are unmet needs, and the hope is that ‘gepants’ will address some of those needs.”

The “gepants” as Dr. Lipton calls them aren’t the only new meds to come on the scene in recent months. A class of drugs known as ditans was approved in December for the acute treatment of Migraine. The first of which, Reyvow (lasmiditan), is said to offer many of the same benefits of triptans without the heart-related complications.

More acute options – like ditans and gepants – will also help people whose Migraine won’t go away with their current medications.

Nurtec (rimegepant) aborts 20% of Migraine attacks in clinical trial

Nurtec ODT was approved by the FDA for the acute treatment of Migraine in adults on February 27, 2020.

One in five people treated with rimegepant in a phase III study reported freedom from pain at 2 hours after a single dose, and nearly 40% reported relief from their most bothersome symptom, usually photophobia.

At the American Headache Society Conference in June 2019, Dr. Lipton presented findings from a double-blind phase III trial that compared Nurtec (rimegepant), an oral CGRP receptor antagonist, to a placebo for the acute treatment of a Migraine attack. The study included 1,072 patients with episodic Migraine (median 4.6 attacks a month) but excluded those with chronic migraine. Participants could continue their Migraine prevention meds while in the trial.

Study findings

After two hours in treatment, 20% of those who received rimegepant reported pain freedom, compared to 12% in the placebo group.

Also after two hours, 58% in the rimegepant group reported pain relief, compared to 43% in the placebo arm.

The benefits of pain freedom, pain relief, return to normal function and freedom from most bothersome symptom were seen with only a single dose of Nurtec ODT

The benefits were sustained up to 48 hours for many patients

86% of patients treated with Nurtec ODT did not require rescue medication within 24 hours of treating with Nurtec


Treatment was generally safe and well-tolerated, Lipton said. The most common side effect in clinical trials was nausea in 4% of participants ( )

Ubrelvy (ubrogepant) aborts 20% of attacks at two doses

Ubrelvy was approved by the FDA for the acute treatment of Migraine in adults on December 23, 2019.

David Dodick, MD, of the Mayo Clinic in Phoenix, presented results from ACHIEVE I, a phase III trial that evaluated another oral CGRP receptor agonist, ubrogepant. The findings were similar to those of rimegepant.

At two hours post-treatment, 19% of patients who received 50 mg of ubrogepant were pain-free

At two hours post-treatment, 21% of those who received 100 mg of ubrogepant were pain-free, compared to 12% of placebo recipients

38% in both ubrogepant groups were free of their most bothersome symptom at 2 hours.

Like rimegepant, ubrogepant was generally safe and well-tolerated.

“This was an acute treatment trial,” Dr. Dodick said. “Patients took the drug for a single attack… More than 40 percent of the patients in this trial were able to return to normal function at two hours,” he said, which is equivalent to what has been found with triptans.

Coming Soon: Ubrelvy and Nurtec ODT

We expect Ubrelvy and Nurtec ODT to available in pharmacies across the U.S. within the coming months. We don’t know how much Nurtec ODT will cost, but it will likely be similar in price to Ubrelvy. The list price for a dose of Ubrelvy is $85, and a pack of 10 doses costs $850. There are copay programs available.

Nurtec ODT is available as quick-dissolving tablets. The tablets disperse almost instantly in your mouth without the need for water, making it a discrete and fast way to treat a Migraine attack.


Nurtec ODT is only approved to treat Migraine attacks. The manufacturer, Biohaven, is conducting trials evaluating its use as a daily preventative. We can expect results within the next month or so.

Too early to tell if new drugs are as effective as triptans

The findings from ACHIEVE I were presented in detail during a session discussion, and physician members of AHS were given the opportunity to comment on the research. While Dr. Dodick was excited to compare the new drugs to triptans, session moderator Elizabeth Loder, MD, MPH, chief of the division of headache and pain at Brigham & Women’s Hospital/Faulkner Neurology and professor of neurology at Harvard Medical School, approached the comparison with caution.

“We don’t have head-to-head comparisons with triptans,” she told the Neurology Today Conference Reporter. “These studies provide more information to the clinician. The drug certainly works better than placebo, but the results seem quite modest.”

Commenting on these two drugs and others described at the same session, moderator Andrew Charles, MD, of the David Geffen School of Medicine at UCLA, told MedPage Today, “How they sort out in comparison remains to be seen, but it shows that the target [CGRP] is an important one and the medications that are going after this target are all working.”

Stay Hopeful

If the new class of meds works, it’s good news for those with heart issues or Migraine that won’t go away with medicine like triptans. The low side effect profile makes these new meds an attractive option for adults with Migraine.


Want to learn more? Be sure to check out our article on Migraine Medication, How to Choose the Right One for your Attack.

Stay hopeful – we’ll keep you posted.

Image: Daniel Hjalmarsson on Unsplash

Updated February 020

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