I heard about gepants, Nurtec, Ubrevly…what are these new medications?  

First, let’s say that “gepant” is the name of a class, or a family of medications, a bit like “triptan” or “anti-inflammatory”. At present time, there are three members of this family available in the US: 

  • Ubrogepant (brand name Ubrelvy, was approved in Canada in 2023)
  • Rimegepant (US brand name Nurtec, expected in Canada in 2024)
  • Atogepant (brand name Qulipta, approved in Canada in 2023)

We did publish a webinar on gepants that you can find HERE.

How do gepants work? What is CGRP?

Briefly put, CGRP is a protein we all have in our bodies. This protein plays a role in migraine, and that is based on very strong scientific research. Gepants block the CGRP receptor, and by doing this blocks the migraine mechanisms. So we can call gepants “CGRP antagonists” or “blockers”.

Are gepants acute or preventive treatments? 

The most unique thing about gepants is that they can be used for the treatment of the attacks (Ubrogepant, Rimegepant), AND/OR for prevention (Atogepant, Rimegepant). That’s a new reality for migraine therapy. 

Up until now, acute treatments were taken as needed for the attack, and preventives were taken every day (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 headaches 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 headaches. That means that someone with frequent migraines could use gepants to treat attacks, and if the gepant is taken frequently, it could have a preventive effect. Indeed, trials have demonstrated that atogepant and rimegepant are beneficial for migraine prevention; thus, it seems highly unlikely that their regular use would increase headache frequency.

Are gepants effective to treat a migraine attack?

Yes. Gepants can be effective to treat 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. Ubrogepant has been shown to be effective when taken 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’s always a balance between effectiveness and side effects.

Do gepants constrict blood vessels (triptans do)? 

One advantage of gepants is that they do NOT constrict arteries. That means they could be used by people with cardiovascular disease (history of heart disease or stroke) or vascular risk factors (diabetes, hypertension, etc.). Always discuss contra-indications with your health care provider.

Are gepants effective for the prevention of migraine? 

Atogepant and rimegepant have been studied for migraine prevention with positive results.
Roughly 50 to 60% of people who try a gepant for prevention will improve by 50% or more.
A third of people who try 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 every day as a preventive treatment?

Side effects reported in the studies were nausea, fatigue, and constipation. 

Side effects reported in the 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. In 2023 Ubrogepant and Atogepant have been approved in Canada. Rimegepant is
expected to be approved in Canada in 2024. It is possible that a primary care provider
will not be aware of these new treatments. Medical education on migraine for health
care providers is available through the Canadian Headache Society (Mastermind Program

Are gepants covered by drug plans?

We will refer you to the Coverage section of our website and to other sources since the
facts on coverage evolve quickly.

Related: See our webinar on DRUG COVERAGE IN CANADA: HOW MEDICATIONS REACH YOUR MEDICINE CABINET

. 

Stay tuned for more information! 

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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