Gepants: preventives AND an acute treatment for migraine
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(US brand name Ubrelvy).
- Rimegepant (US brand name Nurtec)
- Atogepant (brand name not determined yet)
How do gepants work?
Remember CGRP? If you don’t, have a look at our webinar on CGRP antibodies.
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 (Ubro, Rime), AND/OR for prevention (Ato, Rime). 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 meds were limited to 10-15 days per month due to the risk of medication overuse headaches. 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 make the assumption that gepants do not cause medication-overuse headaches. That means that someone with frequent migraine could use gepants to treat attacks, and if the gepant is taken frequently, it could have a preventive effect. Indeed, trials have shown a benefit of atogepant and rimegepant 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 to treat migraine attacks. But, as always, not for everyone. Let’s look at facts from the studies (numbers rounded and sometimes approximated).
| Ubrogepant | Placebo | Rimegepant | Placebo | |
| Pain Relief 2h | 62% | 49% | 59% | 43% |
| Pain Free 2h | 20% | 12% | 21% | 11% |
| Pain relief 24h | 37% | 21% | 48% | 28% |
| Pain Free 24h | 14% | 8% | 16% | 6% |
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.
Are gepants safe?
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.)
Are gepants effective for the prevention of migraine?
Atogepant and rimegepant have been studied for migraine prevention with positive results.
Episodic migraine studies on ATOGEPANT
Patients start with a low baseline of 7,5 days of migraine per month.
50% response rate (ballpark figures, many different doses were tested)
Placebo 30-40%
Atogepant: 52-62%
Episodic migraine study on RIMEGEPANT
Patients start with a low baseline of 7,8 days of migraine per month.
50% response rate (ballpark figures, many different doses were tested)
Placebo: 41%
Rimegepant: 49%
Studies for chronic migraine are not available yet.
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.
Can I ask my health care provider to prescribe gepants to me?
Gepants are not yet available in Canada. They might become available in 2022.
Stay tuned for more information!
REFERENCES
- Negro A, Martelletti P. Gepants for the treatment of migraine. Expert Opin Investig Drugs. 2019;28(6):555-67.
- Lipton RB, Croop R, Stock EG, Stock DA, Morris BA, Frost M, et al. Rimegepant, an Oral Calcitonin Gene-Related Peptide Receptor Antagonist, for Migraine. N Engl J Med. 2019;381(2):142-9.
- Dodick DW, Lipton RB, Ailani J, Lu K, Finnegan M, Trugman JM, et al. Ubrogepant for the Treatment of Migraine. N Engl J Med. 2019;381(23):2230-41.
- Croop R, Goadsby PJ, Stock DA, Conway CM, Forshaw M, Stock EG, et al. Efficacy, safety, and tolerability of rimegepant orally disintegrating tablet for the acute treatment of migraine: a randomised, phase 3, double-blind, placebo-controlled trial. Lancet. 2019;394(10200):737-45.
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