New research has revealed that gepants such as rimegepant could offer a safe and effective alternative in both the treatment and prevention of migraines, providing hope for millions battling this debilitating disease.

5 minute read

Migraines are a common condition that affect over 6 million people in the UK. Symptoms often appear with little or no warning and can blight the lives of sufferers for days at a time.

Rimegepant (Vydura) is a new migraine medication that was recommended by the National Institute for Health and Care Excellence (NICE) as a preventative treatment for migraines in May 2023.

The medication has now been approved to treat acute migraines and could soon be available on the NHS, improving the lives of around 13,000 people.

What is a migraine? 

A migraine is a common neurological disorder that causes a severe headache. It is often felt on one side of the head, but may affect anywhere on the head, neck, or face.

Symptoms of a migraine may vary from one person to another, but often include:

• A moderate-to-severe headache that is often throbbing or pounding

• Nausea (feeling sick)

• Vomiting (being sick)

• Tiredness

• Increased sensitivity to light, sound, and/or smells

Some migraines start suddenly without warning, while others are preceded by an “aura,” which usually starts less than an hour before the headache begins. Auras commonly involve visual disturbances (such as seeing zigzags, blind spots, and flashing lights), numbness, confusion, vertigo, and difficulty speaking. Symptoms of an aura typically last around an hour and resolve as migraine symptoms begin. 

Some people experience symptoms of an aura without a headache (silent migraine).

What is the new treatment for migraines? 

Rimegepant is a disintegrating tablet that dissolves under the tongue. It is manufactured by Pfizer and sold under the brand name Vydura. It is currently the only migraine medication that both treats acute migraine attacks and helps to prevent future attacks.

Because it is dissolvable, rimegepant is absorbed into the blood quickly and normally starts working within ninety minutes.

How does the new treatment work?

Rimegepant is a type of drug known as a Calcitonin gene-related peptide receptor antagonist, or gepant. It works by blocking the action of Calcitonin gene-related peptide (CGRP), a protein produced by the body that is known to cause migraine attacks.

Does rimegepant cause side effects? 

As with all medications, rimegepant can cause side effects in some people. The most common side effects include:

• Nausea

• Dizziness

• Urinary tract infections (UTIs)

• Abdominal pain

• Indigestion

Rarely, rimegepant can cause a severe allergic reaction known as anaphylaxis that needs immediate treatment. 

Most people don’t experience any side effects while taking rimegepant, or side effects are mild and usually resolve after a few weeks. If your side effects are bothering you, getting worse or not going away, speak to your GP or healthcare provider.  

How effective is rimegepant?

Recent research concluded that rimegepant is significantly better at relieving the symptoms of migraine than a placebo and with no difference in side effects. 

One study in the medical journal The Lancet found that 21% of participants taking rimegepant for acute migraine attacks were pain free after 2 hours compared to 11% taking the placebo. 

A further 2020 study on how effective rimegepant is in preventing migraines showed that those taking the drug had 4.3 fewer migraine days per month compared with participants taking the placebo who experienced 3.5 fewer migraine days. 

Another significant benefit of gepants like rimegepant is that they don’t appear to cause medication overuse headaches (rebound headaches) in the way that other acute migraine treatments commonly do. 

The drug was approved in the US by the Food and Drug Administration (FDA) in 2020, and in the UK by the National Institute of Health and Care Excellence (NICE) in May 2023. In September 2023, NICE recommended rimegepant to treat acute migraine attacks in some patients. 

Who is eligible for the new migraine treatment?

Currently, NICE guidelines recommend using rimegepant as a preventative treatment for patients who have at least 4 and fewer than 15 migraine attacks per month, when at least 3 other preventative treatments haven’t worked. 

The drug is recommended for the treatment of acute migraines in people for whom at least 2 migraine medications called triptans have not worked. Or, for people who are unable to take triptans. 

What other treatments for migraines are available?

Currently, there are several treatments available to prevent and treat migraines.

Acute medications

Acute medications are used to treat the symptoms of a migraine when you experience an attack. They include: 

• Painkillers like paracetamol

• Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen 

• Antiemetics (medications to treat nausea) including metoclopramide and domperidone

• Triptans - work by stimulating the production of a chemical called serotonin, which reduces inflammation and narrows the blood vessels in the brain

Preventative medications

Preventative medications are used to prevent or reduce migraine attacks in people who experience them frequently (more than 4 times a month). They are usually taken every day. 

Preventative medications include: 

• Candesartan - a type of angiotensin II blocker normally used to treat high blood pressure (hypertension).

• Anti-convulsants - medications used to treat several conditions, including epilepsy.

• Anti-serotonergic drugs - normally used in the treatment of depression.

• Beta-blockers - a medication used to treat high blood pressure.

• Calcitonin Gene-Related Peptide pathway monoclonal antibodies - new medications specifically developed to prevent migraines. They work in a similar way to rimegepant by targeting CGRP and reducing the frequency and severity of migraines. Calcitonin gene-related peptide pathway monoclonal antibodies are given as an injection monthly or every few months. 

• Calcium channel blockers - work by blocking dopamine receptors in the brain, which can help to reduce migraines.

• Tricyclic antidepressants — are normally used in the treatment of depression.

Botox injections

Botox (botulism toxin type A) is a nerve toxin that is injected into the muscles or under the skin every 3 months. It may be used to prevent migraines in people who experience frequent, chronic migraines and have tried at least 3 other preventative treatments.

It isn’t known exactly how Botox works to prevent migraines, but it is thought to block pain-causing neurotransmitters in the brain.

Greater Occipital Nerve (GON) block

GON is an injection that contains a small amount of a local anaesthetic and/or a steroid. It is injected around one or both greater occipital nerves, the nerves that run along the sides of the back of the head.

GON is used to treat people with disabling headaches and may reduce the frequency and severity of migraines in some people.