Move over triptans--there are several new drugs for acute migraine treatment available in 2020.  And they are:

Nurtec (Rimegepant)

Ubrelvy (Ubrogepant)

Reyvow (lasmiditan)

The first triptan came out in 1991 and these 3 new drugs for acute Migraine therapy work in new and different ways than triptans do. All of these new drugs can be taken with older preventive Migraine drugs such as amitriptyline, or propranolol, and with the new CGRP receptor blockers such as Aimovig and Emgality.

Not all will respond to triptans and triptans have significant possible contraindications. There is a need for other Migraine medications.

This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, podcaster, YouTube video producer, and blogger.

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New Migraine Medication. Nurtec and Ubrelvy block CGRP, the inflammatory chemical released by the Migraine process. Reyvow increases serotonin, which helps Migraine. These drugs can be prescribed for persons with triptan contraindications, such as heart disease.

Related Questions

Are there reports about these new drugs?

Here’s a study regarding these new drugs-”The Institute for Clinical and Economic Review (ICER) has released its report on the clinical effectiveness and economic value of a trio of recently approved acute migraine treatments—lasmiditan (Reyvow; Eli Lilly), rimegepant (Nurtec ODT; Biohaven), and ubrogepant (Ubrelvy; Allergan).”

The ICER organization suggests that all 3 drugs offer a small net health benefit.

How well do these drugs work in comparison with triptans? These 3 drugs decrease symptoms of migraine attacks and improve function compared with placebo. They may be helpful for the 20% of patients who are unable or shouldn’t take triptans.

However, ICER noted that triptans “are similar or more effective than these newly approved agents.”

David Rind, MD, the chief medical officer of ICER said, “For patients who are unable to take triptans or who don’t get adequate benefit from those more affordable options, these new migraine therapies appear to relieve migraine symptoms in 10% to 20% more patients than who respond to placebo.”.

How do these new drugs work? They are all oral drugs. Nurtec and Ubrelvy block the CGRP receptor. CGRP is one of the inflammatory neurochemicals released by the migraine process.

Reyvow works on 5HT 1E receptors which inhibit trigeminal nerve pain pathways. Reyvow also inhibits release of neurotransmitters and neuropeptides.

Reyvoy does not cause arterial vasoconstriction like triptans do and can be used in patients with heart disease, stroke, and hypertension.

What is the expense of these new drugs? ICER suggested that both sumatriptan and eletriptan are both less expensive and more effective than the newer agents.

Nurtec (Rimegepant) is administered as a fast acting orally disintegrating single dosed  75 mg tablet in patients with episodic or chronic migraine.  The study demonstrated a statistically significant reduction from baseline in monthly migraine days in individuals treated with rimegepant compared with placebo.

Treatment provided pain relief within 1 hour.  Nurtec (Rimegepant) had a sustained efficacy of pain relief lasting as long as 48 hours for many patients.

Side effects were few and usually mild.

Serious—hypersensitive reaction which is either immediate or delayed. Side effects may be:

Dyspnea

Severe rash

Common reaction—nausea

This is an unusual drug that works quickly for acute therapy, but also has been approved for episodic and chronic migraine prevention.

Ubrelvy (Ubrogepant)  A recent, December 2019, article in the New England Journal of Medicine found that 20% of patients who received 50 or 100 mg of Ubrogepant orally had freedom from headache pain at 2 hours.  The FDA approved Ubrelvy (Ubrogepant) for acute treatment of migraine.

Side effects of Ubrogepant were:

Nausea

Dry mouth

Somnolence.

Ubrelvy (Ubrogepant) has no effect of vasoconstriction and is okay with heart or stroke conditions.

Reyvow (lasmiditan) is the first and only Ditan for the acute treatment of migraine with or without aura.  Reyvow (lasmiditan) is not indicated for the  preventive treatment of migraine.

Dosing—Three oral dose sizes of Reyvow (lasmiditan) exist-50, 100, and 200 mg.  Only 1 dose should be taken in 24 hours.

The most common adverse reactions were:

Dizziness

Fatigue

Paresthesia

Sedation

Important safety information.

A single dose of Reyvow (lasmiditan) may cause significant driving impairment due to increased sleepiness lasting as long as 8 hours. Therefore, because of this possible side effect patients are advised to not perform potentially hazardous activities requiring complete mental alertness, such as driving a motor vehicle or operating machinery for at least 8 hours after each dose of Reyvow (lasmiditan).

However, the Reyvow drowsiness side effect is dose dependent and may be acceptable with reduced dosing, like taking 50 mg, rather than the 200 mg size dose.

In Summary:

All migraine patients who don’t respond well to triptans, and that is 10 to 20% of patients, should discuss these new drugs with their neurologists. Nurtec is a special new drug with use for both acute and preventive therapy for Migraine. No previous drug has ever worked for combined acute and preventive therapy for Migraine.

Hopefully one of them will help.

Please go to my website at www.doctormigraine.com to read in-depth, individual articles about each of these drugs.

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All the best.

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Britt Talley Daniel MD