New migraine medication: atogepant, rimegepant and CGRP injections

The newest migraine medication works by blocking CGRP, a protein that plays a central role in migraine attacks. There are two groups: the gepants atogepant and rimegepant, which are tablets, and the CGRP monoclonal antibodies erenumab, fremanezumab and galcanezumab, which are injections. They are the first medicines developed specifically for migraine prevention, and for many people they are a turning point.

Which new migraine medicines are there?

CGRP antibody injections

These specially designed proteins (monoclonal antibodies) are injected at home under the skin with an auto-injector pen, usually every 4 weeks. Almost everyone finds this manageable. Three are used:

• Erenumab (Aimovig), which targets the CGRP receptor
• Fremanezumab (Ajovy), which targets the CGRP protein itself
• Galcanezumab (Emgality), which targets the CGRP protein itself

Gepants: atogepant and rimegepant

Gepants are not antibodies but small molecules that block the CGRP receptor. Atogepant (Aquipta) is a tablet and rimegepant (Vydura) is a melt-in-the-mouth tablet. Both can be used to prevent attacks and to treat an attack. Gepants leave the body quickly, which can be an advantage for women who are planning a pregnancy. The downside of a daily tablet is that you have to remember to take it.

How well do the new migraine medicines work?

More than seven years of real-world experience since the first launch show that these medicines keep working in the long term and are well tolerated.

They do not work for everyone, but many people have far fewer migraine days. A fair assessment is usually made after about three months.

How quickly does atogepant work?

Some people notice fewer migraine days within the first few weeks of taking atogepant. As with other preventive treatment, the full effect is usually judged after about three months, using a headache diary to compare migraine days before and after.

How safe are the new migraine medicines?

No important long-term side effects have been shown so far, but there are points to watch. CGRP also has a protective role in the body: it helps keep blood vessels open, for example during wound healing or a threatened heart attack. For that reason, studies keep a close watch on whether users have more heart and blood vessel disease. So far, that has not been the case.

The advice is to be cautious in people at very high risk of heart and blood vessel disease, and to keep an eye on your cardiovascular risk factors. Stopping smoking and checking your blood pressure regularly matter most.

What are the side effects of atogepant and the other new medicines?

• Injections: constipation, and pain, redness or itching where the injection was given
• Atogepant: nausea (often temporary), constipation and tiredness
• Sometimes reported: weight gain, hair loss, poor sleep, tiredness and joint pain. It is not always clear whether these are side effects or complaints that are common anyway in the group most often treated (women aged 40 to 60)

Hardly any of these side effects is a reason to stop treatment.

Where in the body do these medicines work?

An interesting scientific point: the antibody injections are too large to pass the blood-brain barrier. That is good for safety (fewer side effects in the brain), but raises the question of where they work. Current thinking is that they act mainly on the trigeminal nerve, the main headache nerve. Migraine starts in the brain, but the source of the pain lies in this nerve and the blood vessels around it.

Is atogepant available on the NHS?

NICE has recommended atogepant for preventing migraine in adults in specific circumstances, usually when at least three other preventive treatments have not worked. Access and waiting times on the NHS vary by area.

At The Migraine Clinic you do not need a referral. Our care is self-pay and fully online: you see a migraine specialist by video, and if a medicine is prescribed, you pay for it in the App and our partner pharmacy delivers it to your door. See our pricing for details.

Can children use the new migraine medicines?

These medicines are being studied in under-18s, and early results suggest they are effective and safe at that age too. The Migraine Clinic treats adults aged 18 and over.

Is one of these medicines right for you?

Take the migraine test and discuss with a migraine specialist whether one of these new migraine medicines suits your situation. Read more about preventive medication, acute medication and how to start.

This article was written by the medical team of The Migraine Clinic, an online clinic specialised exclusively in migraine.