Migraine Treatment Updates: Zavzpret Nasal Spray and The Nerivio REN Device

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  • Zavzpret Nasal Spray: a new option for acute migraine treatment

  • The Nerivio REN Device: now also indicated for migraine prevention

Zavzpret Nasal Spray

Ever since injectable sumatriptan was approved for use in the US over 30 years ago, the holy grail of “rescue” medication for acute migraine headache of moderate to severe intensity has been a therapy which would offer injectable sumatriptan’s rapid headache relief…without the need for injection, without the bothersome side effects that may occur with sumatriptan, and without the concern that use of the drug might cause a vascular complication such as heart attack or stroke.

On March 10 the FDA approved the latest candidate for this holy grail: zavegepant (Zavzpret). 

Like oral ubrogepant (Ubrelvy) and rimegepant (Nurtec), Zavzpret is a gepant but is the first gepant to be available in a nasal spray formulation. Two well-conducted clinical research studies involving a large number of migraine patients demonstrated the new drug and its delivery system to be safe, well-tolerated and effective for the treatment of acute migraine headache of moderate to severe intensity. In terms of headache relief, Zavzpret was superior to placebo as early as 15 minutes following study drug administration, and for the primary study endpoint of freedom from headache at 2 hours the drug was similarly superior. The most common side effect, occurring in about 1/5th of patients administering Zavzpret, was distortion of taste, with nasal discomfort or nausea occurring much less frequently.

Could Zavzpret represent the long-sought holy grail for acute migraine treatment? Will it prove as effective - and as rapidly effective - as injectable sumatriptan for “rescue” from a migraineur’s most severe migraine headaches?

For some…undoubtedly. For most…probably not. For those motivated to try all three options, Zavzpret nasal spray is likely to provide more rapid relief than an orally administered medication but a slower onset of therapeutic action than that achieved with injectable sumatriptan.

What Zavzpret can offer, however, is a very nice alternative for patients who prefer not to self-inject, for whom nausea precludes oral therapy, whose experience with injectable sumatriptan has been suboptimal or who are excluded from using a triptan consequent to vascular risk factors. And for a disorder as stubbornly multifaceted as migraine, it’s always nice to have another option. 

The Nerivio Device

In 2021 the Nerivio smartphone-controlled neurostimulation device received FDA approval for acute migraine treatment in adolescents, and early in 2021 that indication was extended to include the adult population. The device is attached to an armband easily positioned on the upper arm, where for 45 minutes at a time it transmits low-level electrical pulses through the underlying skin. As with other so-called remote electrical neuromodulation (REN) devices, these electrical pulses are theorized to result in conditioned pain modulation that serves to inhibit pain in sites remote from the application point.

In early March, after review of relevant data from scientifically rigorous clinical research, the FDA extended the indication for Nerivio to include migraine prevention. Used every other day, the device was found to significantly reduce monthly migraine days.

For migraineurs interested in a non-pharmacologic option for reducing their headache burden, the Nerivio device represents a highly tolerable, evidence-based and relatively inexpensive choice.