Ubrelvy vs. Nurtec, Ubrelvy vs. triptans, Nurtec vs. triptans, Ubrelvy vs. Reyvow, Nurtec vs. Reyvow, Reyvow vs. triptans, Rimegepant vs. Ubrogepant, Ubrogepepant vs. triptans, Rimegepant vs. triptans, Lasmiditan vs. Ubrelvy, Nurtec vs. Lasmiditan, Lasmiditan vs. triptans, Ubrogepant vs. Lasmiditan, Rimegepant vs. Lasmiditan. How do you know which one to pick??? Let’s discuss how to pick the best one for you.
First off, these medications are all migraine specific abortive/acute (as needed) options. The goal of migraine abortive treatments is to stop individual migraine attacks at onset so the migraine does not reach full severity, ends quickly, and your function is restored and maintained rather than having to go lay down and miss the whole day in bed. This is in contrast to migraine preventive treatments which are a continuous treatment. Preventive treatments include a daily pill, a monthly/quarterly treatment such as CGRP monoclonal antibodies (Aimovig, Ajovy, Emgality, Vyepti), or neuromodulation devices. The goal of migraine preventive treatment is to lessen the frequency and/or severity of migraine attacks, and these options are discussed in more detail here. If you have migraine, you want to have both a good abortive and preventive treatment plan to lessen migraine's nasty habit of interfering and disrupting life and function.
Since the development and availability of sumatriptan in 1992, the primary migraine specific abortive/acute (as needed) option available has been the triptans. Triptans (Imitrex, Maxalt, etc.) work great for a lot of people. However, about 30% of patients do not respond to triptans. Others cannot tolerate side effects, or they cannot use them because of medical contraindications (such as coronary artery disease, peripheral artery disease, cerebrovascular disease, stroke, etc.). Triptans are also contraindicated in patients with visual snow, persistent migraine aura, and migrainous stroke (infarction). They have been historically contraindicated in hemiplegic migraine or basilar migraine (now called migraine with brainstem aura) due to theoretical concerns of vasoconstriction potentially causing stroke. When the triptan studies were done previously, they excluded patients with these forms of migraine due to the ongoing vascular theory of migraine at that time. The vascular theory of migraine assumed that vasoconstriction and lack of blood flow was the cause of aura and neurologic features with migraine. So the thinking was that if you cause further vasoconstriction with a triptan, you may cause stroke. However, we now know that these phenomenon are primarily of an electrical basis and not a vascular basis. Therefore many specialists have gotten more liberal with the use of triptans in patients with hemiplegic or basilar migraine, and there have been a number of case series and case reports of these patients using triptans without any problems.
The alternatives to triptans have historically been the ergots (ergotamine, DHE) which can be complicated to use, tend to have an excess of side effects for many, and have the same medical contraindications as triptans. NSAIDs and over the counter analgesics are also commonly used, although many do not respond to or cannot take them due to other medical conditions. Even worse are opiates/opioids and butalbital medications such as fioricet, both of which (as do excess triptans, NSAIDS, OTCs) have a high risk of leading to medication overuse headache (rebound headache), as discussed here. For close to 3 decades, these have remained the only limited options of acute/abortive migraine treatment, despite migraine being such a widespread common disorder! More recently, neuromodulation devices have also become available as abortive options.
Thankfully, these limited options have now expanded to 3 new migraine abortive options in adults between 2 new classes which became available commercially in 2020; the gepants and the ditans. These medications can be used SAFELY in all of the medical contraindications mentioned above! These 3 new abortive medications are compared and contrasted with one another, as well as with the triptans in the table which I constructed below.
GEPANTS
The gepants were the first to emerge as new migraine abortive options, first with Ubrogepant (Ubrelvy) which became available from Allergan in January 2020 and then Rimegepant (Nurtec ODT (orally dissolvable tablet)) became available by Biohaven in February 2020.
During a migraine attack, the trigeminal nerves release a variety of inflammatory proteins. One of the main proteins is called CGRP (calcitonin gene related peptide). CGRP causes inflammation around the brain and cerebral arteries (“sterile inflammation”) in the dural membrane surrounding the brain, intensified pain signals, enhanced transmission of pain signals through the trigeminal nerves into the brainstem and into the brain, and dilation of the cerebral arteries through the dural membrane, which in turn leads to further increasing pain signals via the trigeminal nerve endings covering the cerebral arteries. The result is intense migraine pain (as you are unfortunately very familiar with). So, if we can block these steps of migraine pain, the attack should be aborted quickly, and not as severe. That’s the thinking here, and that’s where the CGRP medications (gepants and CGRP monoclonal antibodies) come into play.
Gepants work as CGRP receptor antagonists, which means they directly target and block (antagonist) the CGRP receptor. This results in the medication “blocking” the CGRP inflammatory protein from sticking to the CGRP receptor to activate it, and thus prevents it from “turning on” these pathways of pain. So, you get reversal of cerebral vasodilation, which decreases the firing off of the trigeminal nerves. Notably, the gepants do this in a way that does not cause vasconstriction, in contrast to the triptans. Thus, they are felt to be safe in those with cardiovascular or cerebrovascular disease (as opposed to the triptans). By blocking the CGRP receptor, you also get reversal of the neurogenic inflammation going on through the brain and around the arteries, and you block the electrical transmission of migraine pain from traveling from the trigeminal nerves into the brainstem, and ultimately into the brain.
The side effect profile of the gepants is minimal and similar to placebo compared to the triptans and their alternatives. This is really great to have new options with much less side effect potential. In addition, there is no interaction with using them and triptans, NSAIDs, or other acute meds in case they happen to be taken close together. These medications are not associated with addiction potential, and do not cause medication overuse headache (rebound), which is great! Compared to the triptans and ergots, these medications are NOT contraindicated in patients with stable cardiovascular or peripheral vascular disease or risk factors because they do not cause vasoconstriction (narrowing) of the arteries, which is a HUGE benefit. There are many patients who have been stuck in limbo unable to use standard therapies such as triptans due to other medical problems such as heart disease, so we finally have a safe alternative for them, which is another highlight of these medications.
Safety of these medications in pregnancy or breastfeeding is unknown because they haven’t been studied, and therefore are not recommended. The primary drug interactions to be aware of with these medications are when used with other medications that are metabolized by the liver enzyme system called CYP3A4. Many commonly used medications are metabolized by this system. Strong or moderate inhibitors of CYP3A4 (which slow down the metabolism activity) will cause an increase in gepant exposure. Strong or moderate inducers of CYP3A4 (which increase the metabolism activity) will cause a decrease in gepant exposure and possibly decreased effectiveness. These medications should be avoided in patients with severe liver disease or end stage kidney disease such as those on dialysis.
Many patients use once monthly CGRP antagonist monoclonal antibody (mAbs) self-injections (autoinjection devices) which are FDA approved for migraine prevention (Aimovig (Erenumab), Ajovy (Fremanezumab), Emgality (Galcanezumab), and Vyepti (Eptinezumab), which is a once quarterly 30 minute IV infusion). The CGRP mAbs are discussed in much greater detail and compared with one another here. These have little to no drug interactions and do not affect the liver or kidneys. However, patients often ask if these medications can be used with the gepants given similar mechanisms of action (although much different structure, molecule size, and metabolism). Further confirmatory research is needed, but it is theorized that these medicines can likely be used safely together, and they are metabolized by completely different mechanisms. The gepants are metabolized in the liver, while the CGRP mAbs are metabolized and cleared in the reticuloendothelial system. Furthermore, there is limited evidence suggesting that they may even provide a synergistic effect by working together, but more evidence is needed to confirm this. An insurance battle often ensues when trying to use the large molecule preventive CGRP mAbs with the small molecule abortive gepant medications (Nurtec, Ubrelvy), which also work by a CGRP mechanism. Insurance companies will often not allow these to be used together, despite no good scientific basis. Actually, there is some limited evidence showing that these medications can work synergistically together, which would make sense when taking their mechanisms of action into account. Specifically, there was a publication of data from only a 2-patient cohort showing that the use of these acute and preventive CGRP migraine therapies together can be successful and safe. These two patients had been using rimegepant (Nurtec) in a long-term safety study and had added erenumab (Aimovig). The combination of both successfully aborted 100% of their acute migraine attacks. Certainly we need need larger studies to confirm the suspicion that they likely work together synergistically.
Given that Ubrelvy and Nurtec ODT are of the same gepant class, they each have their own marketing pitch to differentiate them, although the bottom line is that they are both excellent options. Although they are both very effective for most patients, I commonly see patients who may respond to one better than the other. So if one of them does not help, it is worth trying the other one as well.
Ubrelvy (Ubrogepant)
Allergan markets Ubrelvy as quickly relieving migraine pain within 2 hours with just one dose, and that complete elimination of migraine pain with one dose is possible. Furthermore, they highlight that they provide the option of being able to repeat a 2nd dose if needed (similar to how triptans are dosed), with a higher proportion of patients achieving pain freedom 2 hours after taking the optional second dose. They also claim effective relief whether Ubrelvy was taken right away at migraine onset or within 4 hours. The half life is 5-7 hours, so duration of effect is extended compared to many options that we had up to this point. The clinical data highlights of Ubrelvy are that at 1 hour Ubrelvy 50 mg becomes statistically superior to placebo for pain relief, and at 2 hours the 100 mg dose also becomes statistically superior to placebo for pain relief. At 2 hours, both the 50 mg and 100 mg doses become statistically superior to placebo for pain freedom as well as freedom from most bothersome migraine symptom (nausea, photophobia or phonophobia). These benefits could extend into 24 and even 48 hours. In patients who received pain relief with the 1st dose and took an optional 2nd dose of 50 mg, 55% went on to become pain free 2 hours from that point.
Side effects were similar to placebo and the most common were nausea (placebo 2%, Ubrelvy 50 mg 2%, Ubrelvy 100 mg 4%), and somnolence (sleepiness) (placebo 1%, Ubrelvy 50 mg 2%, Ubrelvy 100 mg 3%).
They currently have a savings card program which should work with commercial insurances for $0 per month (16 pills per month). You can get a digital copy of this savings card on your phone to show to the pharmacist if you text UBRELVY to 48764.
Nurtec ODT (Rimegepant)
Biohaven boasts that Nurtec ODT 75 mg dissolves under or on the tongue in seconds, and starts working in minutes (15 minutes in some patients). They highlight that it does not require water or other liquids to take with the dose, so it can be taken anytime and anywhere. It is taken as a simple single strength single dose. They also point out that pain relief and pain freedom lasts up to 48 hours for many patients, which makes sense because it has the longest half-life (11 hours). The clinical data highlights of Nurtec ODT are that at 15 minutes, you get separation from placebo of both pain relief and return to normal function (but not yet statistically superior). At 1 hour, pain relief and return to normal function become statistically superior to placebo. At 1.5 hours, you get additional statistical superiority over placebo of pain freedom and freedom from most bothersome migraine symptom (nausea, photophobia or phonophobia). For the vast majority of patients, the superiority of all of these trial endpoints over placebo remain sustained through 48 hours.
Side effects were similar to placebo and the most common was nausea (placebo 0.4%, Nurtec 2%).
They currently have a savings card program which should work with commercial insurances for $0 per month (8 pills per month). You can get a digital copy of this savings card on your phone to show to the pharmacist if you text NSAVE to 26789.
Notably, on 5/27/21, Nurtec ODT made history as the first and only FDA approved medication for BOTH abortive and preventive migraine treatment simultaneously, and the only option with this flexibility! Nurtec ODT as a preventive migraine treatment is discussed further here. This move followed clinical trials showing that patients taking 75 mg of Rimegepant every other day experienced a 4.3 day reduction from baseline in monthly migraine days, a 30% drop of migraines within even the first week, and 49% of patients had a greater than 50% reduction in monthly migraine days.
Notably, on 9/28/21, Qulipta (Atogepant) became the second oral CGRP preventive gepant medication to become FDA approved for migraine prevention (not dually approved for both abortive and preventive). It is taken once daily. So, Nurtec ODT and Qulipta have become the first oral CGRP preventive medication options. They are both of the gepant medication family, which is different than the CGRP mAb family, but none the less now offer an oral alternative to once monthly CGRP monoclonal antibody injections.
Can I use a CGRP monoclonal antibody (mAb) (Aimovig, Ajovy, Emgality, Vyepti) with Botox injections?
Insurance companies often present various hurdles to using preferred treatment options (the bane of my existence). One common issue for patients with chronic migraine who are receiving Botox injections is that most insurance companies will now make the patient choose between Botox or the CGRP mAb. There is of course no good scientific basis for this, other than the company doesn’t want to pay for both. In fact, there is evidence that using Botox with the CGRP mAbs works better together than with either individually. An abstract presented at the American Headache Society Annual Scientific meeting in June 2020 showed that in patients with chronic migraine and a baseline frequency of 25.7 days per month, the frequency dropped to 14.8 days with Botox, and 9.1 days with Botox plus a CGRP mAb.
Can I use a CGRP mAb (Aimovig, Ajovy, Emgality, Vyepti) with the gepants (Nurtec, Ubrelvy)?
A similar insurance battle often ensues when trying to use the large molecule preventive CGRP mAbs with the small molecule abortive gepant medications (Nurtec, Ubrelvy), which also work by a CGRP mechanism. Insurance companies will often not allow these to be used together, but again, no good scientific basis. Actually, there is some limited evidence showing that these medications can work synergistically together, which would make sense when taking their mechanisms of action into account. Specifically, there was a publication of data from only a 2-patient cohort showing that the use of these acute and preventive CGRP migraine therapies together can be successful and safe. These two patients had been using rimegepant (Nurtec) in a long-term safety study and they had added erenumab (Aimovig) once monthly injection as a preventive treatment. After Aimovig was added, patient 1 had 100% relief for 7 of 7 acute migraine attacks treated with Nurtec. Patient 2 had 100% relief for 9 of 9 acute migraine attacks treated with Nurtec. So, the combination of using Nurtec abortively in addition to using Aimovig preventively appeared to provide an even more effective acute migraine response. Theoretically, it would make sense that benefit would be greater with both classes of medicines combined because they are entirely different types of medications targeting aspects of the same migraine pathway simultaneously (either targeting the CGRP receptor or the CGRP ligand protein). Larger studies to confirm the suspicion that they likely work together synergistically will be helpful.
There was a larger safety study publication which evaluated the acute treatment of migraine with Rimegepant while using a CGRP monoclonal antibody for the prevention of migraine. The CGRP mAbs used were Erenumab (Aimovig) (7 patients), Fremanezumab (Ajovy) (4 patients), and Galcanezumab (Emgality) (2 patients). The study determined that Rimegepant used as an acute migraine treatment in combination with CGRP mAbs for migraine prevention was well tolerated with no safety issues identified. The researchers concluded that the probability between these 2 classes (gepants and CGRP mAbs) was low, especially because they have entirely different pathways of drug metabolism. They also concluded that existing evidence supports the safety of combined use, although further larger research was warranted.
DITANS
Reyvow (Lasmiditan)
The ditans are another new class of migraine abortive, premiering with Lasmiditan (Reyvow) in January 2020 from Eli Lilly. Lasmiditan acts as a high affinity 5-HT1F (serotonin 1F) receptor agonist. The result of its action is a decrease in the release of inflammatory pain producing neurotransmitters and neuropeptides including CGRP from the trigeminal nerves during a migraine attack. These receptors are also involved in modulating other pain signals and blocking (inhibiting) other pain pathways. Notably, like the gepants, they also do not cause arterial vasoconstriction. Again, this is a tremendous benefit and another great option in patients who may not be able to use triptans due to medical contraindications such as coronary or peripheral vascular disease. Caution should be used with other serotonergic drugs given a potential for serotonin syndrome, which was reported in clinical trials.
Similar to the gepants, the Reyvow clinical data highlights showed superiority over placebo at trial endpoints of 2 hour pain freedom, freedom from most bothersome migraine symptom (nausea, photophobia or phonophobia), and pain relief.
In a driving study, 50 mg, 100 mg, or 200 mg doses of Lasmiditan significantly impaired subjects’ ability to drive, and more sleepiness was reported at 8 hours following a single dose compared to placebo. Therefore, patients should wait at least 8 hours between dosing and driving or operating machinery. This can certainly be a drawback in terms of being a treatment option for many patients as the goal of abortive therapy is partly to be able to maintain and restore function in order to not disrupt work, plans, etc. However, if you are in a position where this would not be an issue for you, it could certainly be a valid option to have in your migraine war chest. It should also be used with caution in combination with alcohol or other central nervous system depressants.
Notably, Lasmiditan is a Schedule V controlled substance compared to the other abortive options. Schedule V represents the lowest abuse potential category from the DEA. The reason is because in a human abuse potential study, doses of 100 mg, 200 mg, and a supratherapeutic dose of 400 mg were associated with statistically significantly higher "drug liking" scores than placebo, indicating possible abuse potential. However, it had statistically significantly lower "drug liking" scores compared to alprazolam 2 mg. Lasmiditan also produced adverse events of euphoria and hallucinations to a greater extent than placebo, although it was a low frequency (about 1% of patients). They currently have a savings card program which should work with commercial insurances for $0 per month (4 pills per month).
SUMMARY
The chart below compares and contrasts the treatment outcomes data between Rimegepant, Ubrogepant, Lasmiditan, and Sumatriptan (as representative of the triptan class since it was the first developed). The source of the data comes from the key trials of each medication, as well as some data obtained directly from the pharmaceutical companies. It’s important to note that the trials for each medication did not all include the same data point evaluations, so not all of the comparison data is available across the medications to compare. Also, this data is not reflective of head to head trials between these medications. The data is derived from separate independent trials, many times of which there were variations in study design and endpoints. So, they should not be thought of as head to head comparisons necessarily. In addition, the original triptan studies did not include many of the treatment outcome data points that have become more commonly used since they were developed such as 8 hour data, 2-48 hour data, most bothersome symptom, etc. Therefore, many of these data points within the columns of the different medications may be labeled by N/A (not available).
Overall, these are all very effective and useful medications to keep in mind for your migraine abortive war chest. They are all a welcome and much needed option for the abortive (acute) treatment of migraine. Notably, Ubrelvy, Nurtec ODT, and Reyvow were all proven to be statistically superior to placebo at 2 hours post-dose (some sooner) in terms of pain freedom, pain relief, and freedom from most bothersome migraine symptom (nausea, sensitivity to light (photophobia) or sensitivity to sound (phonophobia)). So there is no "bad" option. Many of the data points are fairly similar with some slight variations, and some data points weren’t compared. Regardless, I have highlighted some of the key differences to take note of in bold print. I hope this data can provide some guidance on some of the differences in these medications which may help to better select them based on the treatment goals, setting of use, and other patient characteristics.
| Rimegepant | Ubrogepant | Lasmiditan | Sumatriptan (100 mg) | |
|---|---|---|---|---|
| Class | Gepant | Gepant | Ditan | Triptan |
| Mechanism of Action | CGRP receptor antagonist | CGRP receptor antagonist | 5HT1F agonist | 5HT1B and 5HT1Dagonist |
| Available dosing | 75 mg orally dissolvable tablet | 50 mg, 100 mg pill | 50 mg, 100 mg, 200 mg (100 mg x 2) pill | 25 mg, 50 mg, 100 mg pill; 3 mg, 4 mg, 6 mg injection; 5 mg, 10 mg, 20 mg nasal spray |
| Max dose per 24 hours | 75 mg | 200 mg | 200 mg | 200 mg |
| Pills per prescription (standard, may be more depending on insurance) | 8 | 10 | 8 | 9 |
| Dosing frequency | 1 dose/24 hours | Dose can repeated once in 2 hours; 2 doses/24 hours | 1 dose/24 hours | Dose can repeated once in 2 hours; 2 doses/24 hours |
| Suggested number of migraine attacks treated per 30 days | 15 (however, currently also being studied as a daily preventive) | 8 | 4 | 10 |
| Time to reach statistically significant pain relief | 60 minutes (however, there was a 15 minute measured clinical beneficial effect) | 60 minutes with 50 mg or higher doses | 30 minutes with 100 mg or higher doses; 60 minutes with 50 mg dose | 30 minutes with 50 mg or higher doses |
| 1 hour significant pain relief | 37% 31% (placebo) | 43% (50 mg) N/A (100 mg) 36.7% (placebo) | 37.3% (50 mg) »41% (100 mg) »46% (200 mg) 30.6% (placebo) | 20-35% (100 mg) 12-21% (placebo) |
| Differences in pain relief at 15 minutes | 8% 5% (placebo) | N/A | N/A | N/A |
| Differences in pain relief at 30 minutes | 19% 17% (placebo) | 19% (50 mg) N/A (100 mg) 20% (placebo) | »15% (50 mg) 17.5% (100 mg) 19.1% (200 mg) 13.4% (placebo) | 11% (100 mg) 12% (placebo) |
| 2 hour pain relief | 59% 43% (placebo) | 61.7% (50 mg) 61.4% (100 mg) 48.7% (placebo) | 59% (50 mg) 59.4-64.8% (100 mg) 59.5-65% (200 mg) 42.2-47.7% (placebo) | 46-67% (100 mg) 18-44% (placebo) |
| 2 hour pain freedom | 21% 11% (placebo) | 20.5% (50 mg) 21.2% (100 mg) 13% (placebo) | 28% (50 mg) 28-31% (100 mg) 32-39% (200 mg) 15-21% (placebo) | 22-33% (100 mg) 3-13% (placebo) |
| 8 hour pain freedom with 1 dose | 56% 33% (placebo) | 82.3% (50 mg) 82.7% (100 mg) 69.8% (placebo) | N/A | N/A |
| 8 hour pain relief with 1 dose | 74% 56% (placebo) | 92% (50 mg) N/A (100 mg) 82% (placebo) | N/A | N/A |
| % of patients with 1st dose pain relief who achieved pain freedom after 2nddose | N/A | 54.7% (50 mg/50 mg) 33.3% (50 mg/placebo) 51.6% (100 mg/100 mg) 33.3% (100 mg/placebo) | N/A | N/A |
| Sustained pain freedom 2-24 hours | 15.7% 5.6% (placebo) | 13.6% (50 mg) 15.4% (100 mg) 8.4% (placebo) | 17.2% (50 mg) 14.8-17.9% (100 mg) 18.6-22.7% (200 mg) 7.6-13.4% (placebo) | N/A |
| Sustained pain relief 2-48 hours | 47.8% 27.7% (placebo) | 31.5% (50 mg) 34% (100 mg) 17.5% (placebo) | N/A | N/A |
| 2 hour absence of most bothersome migraine symptom | 35% 27% (placebo) | 38.7% (50 mg) 37.7% (100 mg) 27.6% (placebo) | 41% (50 mg) 41-44% (100 mg) 41-49% (200 mg) 30-33% (placebo) | N/A |
| 8 hour absence of most bothersome migraine symptom | N/A | 90.9% (50 mg) 92.4% (100 mg) 77.7% (placebo) | N/A | N/A |
| Time to peak plasma concentration TMAX | 1.5 hours | 1.5 hours | 1.8 hours | 1.5-2.5 hours |
| ½ life | 11 hours | 5-7 hours | 5.7 hours | 2-2.5 hours |
| Time to reach pharmacologically active concentration | 15 minutes | Within 11 minutes | N/A | N/A |
| Time the pharmacologically active concentration is maintained | 48 hours | 12 hours | N/A | N/A |
| Notable side effects | Nausea 2% 0.4% (placebo) | Nausea 2% (50 mg) 4% (100 mg) 2% (placebo)
Somnolence/Sedation 2% (50 mg) 3% (100 mg) 1% (placebo) | Nausea 3% (50 mg) 4% (100 mg) 4% (200 mg) 2% (placebo)
Somnolence/Sedation 6% (50 mg) 6% (100 mg) 7% (200 mg) 2% (placebo)
Dizziness 9% (50 mg) 15% (100 mg) 17% (200 mg) 3% (placebo)
Paresthesias 3% (50 mg) 7% (100 mg) 9% (200 mg) 2% (placebo) | Widely variable, most common: Dizziness, fatigue, paresthesias, sedation, nausea, palpitations, anxiety, muscle tightness sensation in chest/neck/throat |
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