Looking for new options in migraine treatment? Gepants are emerging as a promising solution in Canada. This class of medications is specifically indicated for migraine and can be used for both preventive and acute treatment. With proven efficacy, generally mild side effects, and no current indication of medication overuse headache, gepants present an exciting opportunity to discuss with your healthcare provider. In this article, we explore how gepants work, their advantages over other treatments, and their availability in Canada. Learn how these new medications could be a breakthrough in your migraine management strategy.
I’ve heard about Qulipta, Nurtec, and Ubrevly. What are these medications?
Qulipta, Nurtec, and Ubrevly belong to a family of medications known as “gepants.” This term refers to a class of medications, similar to how “triptans” and “anti-inflammatories” are categorized. Currently, there are three gepants available in Canada:
- Ubrogepant (brand name Ubrelvy, approved in Canada in 2023)
- Rimegepant (brand name Nurtec, approved in Canada in 2024)
- Atogepant (brand name Qulipta, approved in Canada in 2023)
How do gepants work? What is CGRP?
CGRP is a protein we all have in our bodies. Based on very strong scientific research, we know that this protein plays a role in migraine. Gepants block the CGRP receptor, and by doing this, they block the migraine mechanisms. So, gepants can also be referred to as “CGRP antagonists” or “CGRP blockers.”
Are gepants acute or preventive treatments?
Gepants are unique because they can be used for the treatment of migraine attacks (Ubrogepant, Rimegepant), AND/OR for prevention (Atogepant, Rimegepant). That’s a new reality for migraine therapy.
Until now, acute treatments were taken as needed for the attack, and preventives were taken daily (for pills) to decrease the frequency of attacks. As a rule, acute medications were limited to 10-15 days per month due to the risk of medication overuse headache. With gepants, these concepts do not apply.
Does that mean that gepants do not cause medication overuse headache, if they can be used every day as preventive therapy?
At the present time, experts and researchers think that gepants do not cause medication overuse headache. That means that someone with frequent migraine attacks could use gepants to treat attacks, and if the gepant is taken frequently, it could even have a preventive effect. Indeed, trials have shown benefits for migraine prevention, so it seems very unlikely that taking them regularly would increase headache frequency.
Are gepants effective to treat a migraine attack?
Yes, gepants can be effective in treating migraine attacks. But, as always, not for everyone. It has been observed that gepants are more effective if they are taken early during the attack, even during the prodrome.
Are gepants better than triptans?
People respond differently to different medications. Triptans seem to be effective for more people, but they also may have more side effects than gepants. When a person evaluates a treatment, it is always a balance between effectiveness and side effects.
Do gepants constrict blood vessels like triptans do?
One advantage of gepants is that they do NOT constrict arteries. This makes them a safe option for people with cardiovascular disease (e.g., history of heart disease or stroke) or vascular risk factors (e.g., diabetes, hypertension, etc.). Always discuss contraindications with your healthcare provider.
Are gepants effective for the prevention of migraine?
Atogepant and rimegepant have been studied for migraine prevention with positive results. Approximately 50 to 60% of people who try a gepant for prevention will improve by 50% or more. A third of people who try gepants will get a super-response (75% better). These results are better than what has been seen with older oral preventives.
What are the side effects of taking atogepant or rimegepant daily as a preventive treatment?
Side effects reported in studies include nausea, fatigue, and constipation. Overall, gepants are likely better tolerated than older oral preventives. However, they are newer, and long-term observations are still ongoing.
Are gepants available in Canada?
Yes, ubrogepant and atogepant were approved in Canada in 2023, and rimegepant was approved in 2024. It is possible that a primary care provider will not be aware of these new treatments. Medical education on migraine for healthcare providers is available through the Canadian Headache Society.
Are gepants covered by drug plans?
The coverage landscape is constantly evolving. For more information, please watch our webinar on Drug Coverage in Canada: How Medications Reach Your Medicine Cabinet.
For more information on gepants, please watch our webinar on gepants with Dr. Elizabeth Leroux.
References
- Argyriou AA, et al. A systematic review with expert opinion on the role of gepants for the preventive and abortive treatment of migraine. Expert Rev Neurother. 2022;22(6):469-88
- Dodick DW, et al. Ubrogepant for the Treatment of Migraine. N Engl J Med.2019;381(23):2230-41.
- Dodick DW, Goadsby PJ, Schwedt TJ, Lipton RB, Liu C, Lu K, et al. Ubrogepant for the treatment of migraine attacks during the prodrome: A phase 3, multicentre, randomised, double-blind, placebo-controlled, crossover trial in the USA. Lancet. 2023;402(10419):2307-16.
- Blumenfeld AM, et al. Efficacy of ubrogepant based on prior exposure and response totriptans: A post hoc analysis.Headache. 2021;61(3):422-9
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