rimegepant for treating acute migraine

Last edited 10/2023 and last reviewed 11/2023

The trigeminovascular system is now known to have a significant role in the initiation of migraines, including the release of pain mediators such as calcitonin gene-related peptide (CGRP) and substance P (1)

• when administered, calcitonin gene-related peptide (CGRP) has been shown to cause mast cell degranulation and cerebral vasculature vasodilation leading directly to the development of migraine
• two main classes of CGRP modulators have been developed:
  • CGRP receptor antagonists (gepants)
  • CGRP monoclonal antibodies
  • both gepants and CGRP monoclonal antibodies are believed to target peripheral CGRP receptors
• rimegepant is a second-generation gepant that was first introduced in 2012
  • is a CGRP receptor antagonist approved for the acute treatment of migraine with or without aura in adults, and for the preventive treatment of episodic migraine in adults (2)
• based on the currently existing evidence, rimegepant appears to be an effective and safe acute migraine treatment with few adverse effects (1)
  • the most common and promising effects include freedom from pain and freedom of most bothersome migraine-related symptoms when used as an acute treatment

NICE state:

• Rimegepant is recommended as an option for the acute treatment of migraine with or without aura in adults, only if for previous migraines:
  • at least 2 triptans were tried and they did not work well enough or
  • triptans were contraindicated or not tolerated, and nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol were tried but did not work well enough

The NICE committee note that "..Clnical trial evidence for acute migraine shows that rimegepant is more likely to reduce pain at 2 hours than placebo.."

Reference:

• Berger AA, Winnick A, Carroll AH, Welschmeyer A, Li N, Colon M, Paladini A, Ramírez GF, Hasoon J, Cornett EM, Song J, Varrassi G, Kaye AM, Kaye AD, Ganti L. Rimegepant for the treatment of migraine. Health Psychol Res. 2022 Oct 12;10(5):38534. doi: 10.52965/001c.38534. PMID: 36262478; PMCID: PMC9560892.
• Blair HA. Rimegepant: A Review in the Acute Treatment and Preventive Treatment of Migraine. CNS Drugs. 2023 Mar;37(3):255-265. doi: 10.1007/s40263-023-00988-8. Epub 2023 Feb 4. Erratum in: CNS Drugs. 2023 Jul 4;: PMID: 36739335; PMCID: PMC10299922.
• NICE (October 2023). Rimegepant for treating migraine