Recent approval of ubrogepant for treatment of acute migraine is discussed, as well as the overall use of CGRP receptor antagonists in clinical practice for acute migraine.
Robert Cowan, MD, FAAN: Ubrogepant is also a CGRP antagonist, and it has a very similar profile to rimegepant in terms of tolerability and efficacy. At this point, the molecule has not been tested for prevention, so we don’t have data to suggest that it is safe to take on a daily or near-daily basis. But used as an acute rescue treatment, it can be very effective.
If you decide as a physician or a provider that you’re going to use 1 of the CGRP antagonists, patient selection can sometimes be limited by payer decisions. New drugs are generally more expensive, and sometimes there are coupons and special deals made available in order to gain access to these medications. But very often, there will be a step edit requiring that 1 or more triptans be trialed and failed before you can get access to them. That’s a bit of a moving target. We’ll have to see how that plays out over time.
At this point, I don’t have enough experience with ubrogepant. I’ve been using mostly rimegepant, but I have not seen any data to suggest 1 would be favored over the other with the exception of having the advantage of data for long-term use with rimegepant.
The CGRP antagonists are not currently being used as first-line treatments, mostly because of access issues, rather than anything pharmacological. In patients who have not done well, could not tolerate, or have contraindications to triptans, they are being used increasingly in that function.
The CGRP antagonists are of particular usefulness in patients who have headaches frequent enough to result in medication-overuse headache. That’s a setting in which we would like to transition to or add CGRP antagonists in order to avoid medication overuse.