Use in Adults
CGRP Antagonists - Oral

THIS GUIDE PROVIDES A PARTIAL LISTING OF PRESCRIBING INFORMATION FOR THIS MEDICATION. FOR A FULL LISTING OF PRESCRIBING INFORMATION PLEASE REFER TO THE PACKAGE INSERT. CLICK ON THE BRAND NAME® TO VIEW THE LINK TO THE PACKAGE INSERT.
Atogepant (Qulipta®) FDA APPROVED FOR Acute MIGRAINE PREVENTION ​CLICK HERE TO EXPAND ​
Brands: Available Dosages:
  • 10, 30 and 60 mg tablets
Initial Dose:
  • 30 mg by mouth daily is the most common dosage
  • Some headache specialists would start with 60 mg by mouth daily in more refractory patients
​Maintenance Doses: 
  • 30 mg or 60 mg by mouth daily
Suggested Titration Schedule:
  • Office visit #1
    • Start 30 mg by mouth daily
  • Office visit #2
  • If satisfactory response (e.g., defined as a 50% decrease in the frequency of migraine days per month) then continue current dosage, if no unacceptable side effects
  • If unsatisfactory response, consider increasing the dosage to 60 mg by mouth daily if the 30mg dosage was well tolerated
​​Common Side Effects:
  • Nausea, constipation (6% in clinical studies), drowsiness and fatigue
Headache Specialist Suggestions
  • Consider its use in:
    • Those with episodic migraine
    • Those who are intolerant to oral medications, as its side effects are generally low
    • Those with medication overuse may be considered, no evidence, as yet, that daily use causes medication overuse, though studies are relatively short 
  • Avoid its use in:
    • Chronic migraine, where it does not have FDA approval
    • Moderate to severe constipation
  • Advantages are:
    •  Good efficacy, low side effect profile and apparent low risk of inducing medication overuse headaches.
    • Possible weight loss 
  • Disadvantages are:    
    • Cost and need for a prior authorization
    • No long-term safety data available, as yet
Precautions and Risk:
  • Severe renal impairment or ESRD: start with 10 mg by mouth once daily.
  • Avoid in severe hepatic impairment.
Contraindications:
  • Hypersensitivity to atogepant
  • Would avoid in those with recent cardiovascular events in the prior 6 months as these participants were excluded from the clinical trials. 
Pregnancy & Breast Feeding:
  • Click Qulipta® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
Important Drug Interactions:
  • Strong CYP3A4 Inhibitors (e.g., clarithromycin, erythromycin, diltiazem, itraconazole, ketoconazole, ritonavir, verapamil, goldenseal and grapefruit):
    • May increase serum levels of atogepant; would use 10 mg by mouth once daily as the initial dosage.
  • Strong and Moderate CYP3A4 Inducers (e.g., phenobarbital, phenytoin, rifampicin, St. John's Wort and glucocorticoids):
    • May decrease serum levels of atogepant; use either 30 mg or 60 mg by mouth once daily as initial dosage.
  • OATP Inhibitors (e.g., atorvastatin, cyclosporin, gemfibrozil and others):
    • May increase serum levels of atogepant; use the 10 mg or 30 mg by mouth once daily as initial dosage.
Counseling Tips:
  • Consider starting a preventive therapy in those with 4 or more migraine days per month.
  • Have the patients keep a headache diary to assess the frequency of migraine days per month.  This will also help in assessing the response of the preventive medication.
  • Counsel patients that it may take 1-4 months after the start of an oral preventive to see an adequate response.
  • Set realistic goals with your patients.  Tell them that a preventive medication is not a cure for migraines.  A good response would be a 50% or more reduction in the frequency of migraine days per month.
  • Counsel patients on side effects or they may discontinue the medication.
  • Offer a 3-4 month trial of this medication to access efficacy. 
Rimegepant (Nurtec®) FDA APPROVED FOR Acute MIGRAINE PREVENTION ​CLICK HERE TO EXPAND 
Nurtec ODT® (rimegepant) For Complete Prescribing Information Click Here for the Package Insert
Available Dosages:
  • 75 mg tablet
Initial Dose:
  • 75 mg by mouth every other day
​Maintenance Doses:
  • 75 mg by mouth every other day
Suggested Titration Schedule:
  • No titration necessary as only one dosage indicated for episodic migraine prevention
​​Common Side Effects:
  • Nausea, abdominal pain, dyspepsia
Headache Specialist Suggestions:
  • It was the first migraine drug to receive FDA approval for both acute migraine treatment and for prevention of episodic migraine
  • Consider its use in:
    • Those with episodic migraine, who have not responded to oral agents or CGRP monoclonal antibodies for migraine prevention
    • Those with medication intolerances since side effect profile is low.
    • Those with medication overuse
      • rimegepant has not been found to cause medication overuse headaches  
  • Avoid its use in:
    • Chronic migraine, as its approval is for prevention of episodic migraine
  • Advantages are:
    •  Good efficacy, low side effect profile and low risk of inducing medication overuse headaches.
    • Can be used both acutely and preventively
      • could be used preventively during time periods of high migraine frequency (e.g., seasonal worsening) and acutely during times of low migraine frequency
  • Disadvantages are:    
    • Cost and need for a prior authorization
    • No long-term safety data is available, as yet
Precautions and Risk:
  • Hepatic impairment: Use is not recommended in patients with severe hepatic impairment.
  • Renal impairment: Use is not recommended in patients with end-stage renal disease.
Contraindications:
  • Hypersensitivity to rimegepant
  • Would avoid in those with recent cardiovascular events in the prior 6 months as these participants were excluded from the clinical trials. 
Pregnancy & Breast Feeding:
  • Click Nurtec ODT® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
Important Drug Interactions:
  • Strong CYP3A4 Inhibitors (e.g., clarithromycin, erythromycin, diltiazem, itraconazole, ketoconazole, ritonavir, verapamil, goldenseal and grapefruit)
    • Avoid concomitant administration.
  • Strong and Moderate CYP3A Inducers (e.g., phenobarbital, phenytoin, rifampicin, St. John's Wort and glucocorticoids)
    • Avoid concomitant administration.
  • Inhibitors of P-glycoprotein or BCRP, human breast cancer resistance protein
    • Avoid concomitant administration.
Counseling Tips:
  • Consider starting a preventive therapy in those with 4 or more migraine days per month.
  • Have the patients keep a headache diary to assess the frequency of migraine days per month.  This will also help in assessing the response of the preventive medication.
  • Counsel patients that it may take 1-4 months after the start of an oral preventive to see an adequate response.
  • Set realistic goals with your patients.  Tell them that a preventive medication is not a cure for migraines.  A good response would be a 50% or more reduction in the frequency of migraine days per month.
  • Counsel patients on side effects or they may discontinue the medication.
  • Offer a 3-4 month trial of this medication to access efficacy. 
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