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
- 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
- 30 mg or 60 mg by mouth daily
- 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
- Nausea, constipation (6% in clinical studies), drowsiness and fatigue
- 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
- Severe renal impairment or ESRD: start with 10 mg by mouth once daily.
- Avoid in severe hepatic impairment.
- 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.
- Click Qulipta® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- 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.
- 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:
Available Dosages:
- 75 mg tablet
- 75 mg by mouth every other day
- 75 mg by mouth every other day
- No titration necessary as only one dosage indicated for episodic migraine prevention
- Nausea, abdominal pain, dyspepsia
- 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
- 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.
- 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.
- Click Nurtec ODT® and navigate to #8 Use in Specific Populations (8.1 & 8.2)
- 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.
- 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.