‘Gepants’: A New Option for Acute and Preventive Migraine Treatment

When you have migraine, treatment usually falls into two general categories: acute medicine you take during an attack or preventive medicine you take regularly to reduce how often attacks happen.

That broader role — and a better side effect profile than other treatments — is part of the appeal, says William Jarrard, MD, an assistant professor of medicine and neurologist at the Medical University of South Carolina in Charleston. “These newer medications, including gepants, have truly been game changers in migraine treatment,” says Dr. Jarrard.

What Are Gepants?

That's what makes gepants “a great treatment for migraine,” says Daod Pak, MD, a neurologist at Stony Brook Medicine on Long Island, New York.

They also come in several forms, including tablets, dissolving tablets, and nasal spray, so they are easier to match to a person’s symptoms and preferences, says Dr. Pak.

Approved gepants include these forms:

• ubrogepant (Ubrelvy) for acute treatment
• rimegepant (Nurtec ODT) for acute treatment and prevention
• zavegepant (Zavzpret) as a nasal spray for acute treatment
• atogepant (Qulipta) for prevention only

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Not every gepant plays the same role in migraine treatment. Some are used to stop a migraine after it starts, while others help prevent attacks from happening as often, says Pak.

How Do Gepants Compare to Other Acute Treatments?

In addition to gepants, other options for treating a migraine attack include over-the-counter pain relievers, triptans, dihydroergotamine, and anti-nausea medicines.

Gepants are a strong alternative to older migraine medicines, says Pak. “They are considered when patients have not responded to more traditional medications, such as triptans,” he says.

“Gepants can also be considered a first-line treatment, depending on the patient,” says Pak.

Efficacy

Ubrogepant In a 52-week extension study, ubrogepant led to freedom from pain after two hours in 23 to 25 percent of attacks and pain relief after two hours in about 65 to 68 percent of attacks. It worked even better when taken early — while pain was still mild — with two-hour pain freedom rising to about 51 to 54 percent.

Rimegepant Rimegepant has shown sustained efficacy as an acute treatment in long-term studies. A review also found that it worked about as well in people with prior triptan failure as it did in current triptan users and people who had never used a triptan, based on two-hour pain freedom and relief of the most bothersome symptom.

Zavegepant The nasal spray zavegepant can relieve migraine pain within two hours and may keep helping for up to 48 hours. Nasal delivery may be especially useful for people who have nausea or vomiting during an attack, when taking a pill can be harder.

Side Effects

Cost

Depending on your prescription insurance coverage, cost may be an issue. Several triptans are available as generics, which tend to be much less expensive than brand-name drugs. Gepants are newer and may still come with insurance hurdles or high copays.

“Traditionally, people had to try other therapies first before gepants were approved by their insurance,” says Jarrard. However, that has started to change, and some insurance plans are covering them without requiring other therapies first, he says.

“If you have a high copay, some of the manufacturers offer savings cards to help with the cost,” says Pak.

How Do Gepants Compare to Other Preventive Treatments?

Preventive migraine treatment has traditionally included drugs originally developed for other conditions, such as beta-blockers for blood pressure, anti-seizure medicines like topiramate, and antidepressants like amitriptyline.

The review found that gepants reduced monthly migraine days by about 3.6 to 4.4 days at 12 weeks. Older drugs, including topiramate and propranolol, also reduced migraine days, but side effects were more frequent and difficult to tolerate.

Cost and insurance concerns for gepants for preventive use are similar to the access barriers in acute migraine treatment.

Talking to Your Doctor About Trying Gepants

If your current medication is not providing relief or provides only partial relief, or if side effects are an issue, talk with your doctor, says Pak.

Gepants can be considered at several points in care, including at diagnosis, says Jarrard.

The more detailed you can be in describing your migraine attacks, the better. Experts suggest being ready to share the following information with your doctor:

• How often your migraine attacks happen
• How well your current medicine works
• Whether you need repeat doses
• How many doses of acute treatment you are taking per month
• Any side effects you’ve had
• Whether nausea or vomiting makes pills harder to take
• What other medical conditions you have or other medications you’re taking, which might affect your migraine treatment options

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“People with four or more migraine days a month may benefit from preventive treatment,” says Jarrard. Not only will reducing your headache days improve your ability to function but it can also reduce the likelihood of developing rebound headaches, which can happen if you take acute treatment too often, he says.