Grand Rounds

The New Migraine Medication: Is Rimegepant Effective?

BACKGROUND AND PURPOSE:

Triptans are commonly prescribed for migraines but is not always effective and is contraindicated in some patients (e.g., CVD)
Calcitonin gene–related peptide (CGRP) is part of the pathway related to migraine symptoms
Lipton et al. (NEJM, 2019) conducted a phase 3 trial to evaluate the efficacy and safety of rimegepant (oral dose of 75 mg), compared to placebo, in acute migraine treatment

Multicenter, double-blind, phase 3 trial
Participants
- ≥1-year history of migraine
- 2 to 8 attacks per month (moderate or severe intensity)
Groups
- Rimegepant group: 75 mg when a single migraine attack occurred
- Placebo group: Matching placebo
Primary outcomes (assessed 2 hours after dose)
- Freedom from pain
- Freedom from the most bothersome symptom (other than pain)

1,186 patients | 88.7% were women | Mean age: 40.6 years
- Rimegepant group: 537 evaluated
- Placebo group: 592 patients
Rimegepant use resulted in a significantly greater percentage of patients who were pain free at 2 hours post migraine attack
- Rimegepant group: 19.6%
- Placebo group: 12.0%
- Absolute difference: 7.6 percentage points (95% CI, 3.3 to 11.9; P<0.001)
Rimegepant use resulted in a significantly greater percentage of patients who were free of the most bothersome symptom at 2 hours post migraine attack
- Rimegepant group: 37.6%
- Placebo group: 25.2%
- Absolute difference, 12.4 percentage points (95% CI, 6.9 to 17.9; P<0.001)
Most common adverse side effects
- Nausea: 1.8% in the rimegepant group | 1.1% in the placebo group
- UTI: 1.5% in the rimegepant group | 1.1% in the placebo group

Rimegepant was superior to placebo for the treatment of moderate or severe migraine attacks
The authors recommend “larger and longer trials” to determine long term outcomes and safety profile

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