Good news…. we now have 2 new medications for the acute treatment of migraine. Both are oral tablets and represent alternatives for those who have unmet acute migraine treatment needs. The triptans, first introduced in the United States in 1992, have been the mainstay of treatment for years. They include Imitrex, Maxalt, Zomig, Relpax, Axert, Amerge, and Frova. Most are generic and inexpensive. Are the new medications better? For some patients, they may be.
The goals for acute migraine treatment are to be headache free and back to full function in 2 hours after taking the acute medication like Imitrex. If your migraine treatment is not consistently bringing you to headache freedom in 2 hours you would be a candidate for Ubrelvy or Reyvow. In addition, if you are putting up with “triptan sensations” like neck/chest tightness, flushing, fatigue, nausea, or worsening of the headache before it gets better, you may tolerate Ubrelvy or Reyvow better. Lastly, if you have a contraindication to the triptans due to coronary artery disease, peripheral vascular disease, or multiple cardiac risk factors, these new medications would be safer as neither Reyvow nor Ubrelvy cause vasoconstriction.
Ubrelvy (Ubrogepant) is the first oral “gepant” to be FDA approved. It is an oral CGRP (calcitonin gene-related peptide) antagonist and works by blocking at the CGRP receptor site. In binding to this receptor site, it prevents the CGRP peptide that is released during migraine to attach and thereby, prevents the pathway of migraine. Numerous studies have shown that CGRP gets elevated during migraine. To learn more go to www.scienceofmigraine.com. Ubrelvy does not cause vasoconstriction, is very well tolerated in clinical trials, and so far, does not appear to cause medication overuse headache. It is available as a 50 mg & a 100 mg tablet and may be repeated in 2 hours. Ubrelvy comes in a package of 10 and for patients with commercial insurance, is available for $10 per 10 tablets per month. To learn more, go to www.Ubrelvy.com and to access the savings program, go to www.Ubrelvy.com/savings. If you are up-to-date on your visit with us, we may be willing to send in a Rx for Ubrelvy prior to your next visit. If interested, please email us at firstname.lastname@example.org.
Reyvow (Lasmiditan) works differently than Ubrelvy. It is a 5-HT1F serotonin receptor agonist and is referred to as a “ditan” Reyvow binds to the 5-HT1F receptor activating it, which then inhibits pain pathways and inhibits release of neuropeptides like CGRP. It is not associated with vasoconstriction or medication overuse headache. However, it crosses into the central nervous system (CNS) and as such, can cause drowsiness and sedation. As a result, it is a controlled medication and is Schedule 5 by the DEA. Schedule 5 represents medications that have the least addictive potential. Reyvow comes as a 50 and 100 mg strength tablet and is dosed as 50 mg, 100 mg or 200 mg as a single dose in a 24-hour period. There is a driving restriction for 8 hours due to the potential sedation and dizziness seen in clinical trials. Reyvow may be useful as a rescue option when an individual is home for the day with a moderate to severe migraine and does not plan on driving for 8 hours. As headache specialists, we are hopeful that Reyvow can take the place of Butalbital products including Fiorinal & Fioricet as well as Hydrocodone Products such as Vicodin & Norco. To learn more go to www.Reyvow.com. Reyvow has a savings program for those with commercial insurance. Using the savings program, an individual should be able to get 8 tablets per month for zero copay. Information about the savings program is available at www.Reyvow.com. Because Reyvow is a controlled medication, please make an appointment with us if you are interested in trying. We need to carefully review the potential side effects with you.
Other medications will be coming soon including Rimegepant, another oral gepant for acute migraine. In 1-2 years, Atogepant, a 3rd oral gepant, should be available and will be for the prevention of migraine.
This is truly an exciting time in migraine. With new treatment options, comes new hope for a brighter future for all individuals with migraine.
We look forward to working with each of you to optimize your headache treatment plan.
Dr. Susan Hutchinson & Dr. Molly Rossknecht
February 12, 2020