The pharmacotherapeutic management of episodic and chronic migraine with gepants

ABSTRACT

Introduction

The small molecule non-peptide calcitonin gene-related peptide (CGRP) receptor antagonists named gepants offer a breakthrough novel approach in migraine acute and prophylactic drug treatment. This review aimed to determine the place of gepants in the treatment of episodic and chronic migraine.

Areas covered

The new generation gepants are ubrogepant, atogepant, rimegepant, and zavegepant. Ubrogepant is ratified for acute migraine treatment, atogepant is validated for preventive therapy, whereas rimegepant is ratified for both indications, all via oral administration and while zavegepant is administered intranasally for migraine attacks. Gepants are effective, safe, and well-tolerated in acute or prophylactic therapy. The PubMed literature search included randomized controlled trials, meta-analyses, real-world data, and review articles published in English until January 2023.

Expert opinion

Whether gepants will be real game changers in the acute treatment of migraine compared to triptans and ditans or in the prophylactic therapy compared to standard-of-care preventive drugs or CGRP-targeting monoclonal antibodies cannot be answered yet based on the available literature data.

KEYWORDS:

• CGRP receptor
• chronic
• episodic
• gepant
• migraine
• treatment

Article highlights

• CGRP is a well-characterized migraine-associated neuropeptide, which acts on the trigeminovascular system.

• Previous acute and prophylactic therapeutic options do not provide pain relief for all patients with migraine.

• Gepants as small-molecule non-peptide CGRP receptor inhibitors offer a novel approach in the acute treatment for migraine with and without aura and in the prophylactic drug treatment for episodic migraine. No published data are available regarding chronic migraine.

• Ubrogepant (oral) and zavegepant (intranasal) are consented for acute migraine treatment, atogepant (oral) is validated for preventive therapy, whereas rimegepant (standard and orally disintegrated tablets, oral) is validated for both indications.

• All available gepants are effective, safe, and well-tolerated in the acute and prophylactic treatment of migraine based on the results of randomized controlled trial.

• This review discusses the possibility whether gepants can become real game changers in migraine treatment.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Data availability statement

This work is a review. The data used to prepare this work are available in the cited sources.

Reviewer disclosures

Peer reviewers of this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.