The Changing Treatment Landscape for Acute Migraine - Episode 5

Real-World Experience With Gepants for Acute Migraine

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David W. Dodick, MD: I’ve used rimegepant, ubrogepant, and lasmiditan, actually. My experience with the gepants is that the tolerability profile seen in clinical trials appears to be true in clinical practice. They appear to be well tolerated so far.

In terms of efficacy, I haven’t systematically looked at all the data. So it would be unfair to give you any numbers in terms of the proportion of patients who are responding, because that would require us to go into a database and start systematically looking to see how many patients are responding, how many patients are continuing with the medicine, and what it means to respond. The definitions that we use in clinical practice and that patients use are a little looser than what’s used in clinical trials. All I’ll say is that my experience with gepants, including rimegepant, is that yes, of course patients respond. The tolerability appears to be favorable, much as it was in clinical trials. However, I need more experience in more patients and with more systematic collection of data to see exactly how patients are responding. Is it true that patients who use it when pain is mild get a better response? I think that’s the case, but without going in and looking at the data, I’m talking off the top of my head with a limited sample. These drugs haven’t been around that long. They’ve been around for only a few months. Given that we’re living in a pandemic, our ability to rigorously and systematically follow patients has been hampered somewhat. So there are a lot of circumstances that preclude me from giving you a definitive answer to that question.

Some decisions are taken out of our hands as doctors. If an insurance company won’t reimburse or cover the medication and provide access to the medication for the patient—if they haven’t failed at least 2 different oral triptans—then they’ve taken that decision out of my hands. If I see you, as a patient, and you’ve never been on a triptan before, or your insurance requires the failure of 2 triptans and you’ve only been tried on 1, I can’t even use these medicines. It’s important to recognize that the decision is not up to me and not up to the patient. It’s up to the insurance carrier.

Let’s put that aside for a second, and let’s say a patient meets requirements for access. They’ve taken 2 triptans and failed to respond or failed to tolerate the triptans. That would be a patient for whom I would select a gepant.

In patients who have acute medication overuse or who have chronic migraine and are using at least 10 days of an acute treatment, that’s a patient population for which I would suggest using a gepant as treatment. As we talked about earlier, gepants don’t appear to cause overuse headache, at least in preclinical animal models and clinical practice and clinical trials using gepants for prevention. So that’s another patient population for whom I look to a gepant.

In patients who have a contraindication to the use of triptans—they have vascular disease or uncontrolled hypertension—I would look to a gepant. Those are just some patient populations who would be eligible for a gepant early on.