Rimegepant: A new option for pain-free migraines?

An anti-migraine oral CGRP antagonist achieved pain relief in some patients in a recent placebo-controlled study. The extent of the antagonist's effectiveness when compared to a triptan remained unclear.

CGRP antagonists relieve pain and associated symptoms

An oral CGRP antagonist against migraine achieved pain relief in some patients in a recent placebo-controlled study. The extent to which the CGRP antagonist is more effective than a triptan in such cases remained unclear.

For a long time, the treatment of migraine was a field without any real innovations. Since the introduction of the so-called Calcitonin Gene-Related Peptides (CGRP), this has changed significantly. Prophylactically, physicians can now rely on three CGRP antagonists: Erenumab, Galcanezumab, and Fremanezumab. A recent study has tested the CGRP receptor antagonist Rimegepant to examine the extent to which this drug could alleviate the pain and accompanying symptoms of migraine attack patients.

Less pain and fewer accompanying symptoms

The placebo-controlled multicenter study included a total of 1,186 patients. All patients had experienced migraines for at least one year and had between two and eight moderate to severe attacks per month.

The majority (approx. 89%) of participants, were on average 41 years old, and female. When an attack occurred, the patients took either a tablet containing 75 mg Rimegepant (n = 594) or a corresponding placebo (n = 592). With the help of a questionnaire, the physicians determined the intensity of the pain and accompanying symptoms of the migraine attacks. The co-primary endpoint was a complete absence of pain and absence from the individual accompanying symptoms.

Almost 20% were pain-free

In the Rimegepant group, almost 20% of participants achieved the absence of pain, in the placebo group the proportion was only 12%. In the verum group, 37.6% of the participants stated that the strongest accompanying symptoms had disappeared, while in the placebo group the figure was 25.2%.

The side effect profile of the verum showed nausea (1.8% Rimegepant group vs. 1.1% placebo). Furthermore, urinary tract infections occurred (1.5% verum, 1.1% placebo). Serious side effects were very rare (<0.5%).

Do these results have implications for current medical practice?

The study showed that CGRP antagonists can be used to relieve migraine pain. However, the long-term safety of such applications remains insufficiently clarified. In addition, it should not be forgotten that the studies available so far excluded several patient groups, which in everyday life make up the majority of patients with migraine. These include, for example, those with vascular diseases, serious respiratory tract diseases or of the intestines.

Original publication: 
Lipton BL et al., Rimegepant, an Oral Calcitonin Gene-Related Peptide Receptor Antagonist, for Migraine; N Engl J Med 2019; doi:10.1056/NEJMoa1811090