After I complete my evaluation of a new migraine patient who has come to my clinic, we sit together to plot strategy. When one considers how to treat migraine with medication, the watershed management decision typically comes down to this: should the patient use only “as needed” medication intended for acute migraine treatment, or does the patient also require a course of prevention therapy so as to stabilize his/her migraine?  

For patients who have high frequency episodic or chronic migraine and by definition are experiencing 9 or more headache days per month, the medication regimen prescribed is usually a prevention therapy plus 2 or 3 therapies to be used as needed for acute headache, with the choice of which therapy to use depending largely upon headache intensity.

For patients whose headache frequency is lower, however, it may be more difficult to justify the risk of side effects and inconvenience associated with an oral medication taken at least once daily.  With their high tolerability and the convenience afforded by once-monthly subcutaneous self-injection, the anti-CGRP monoclonal antibodies (Aimovig, Emgality, Ajovy) have made the prospect of prevention therapy for patients with 4, 5 or 6 headache days monthly more palatable.

Now there is another alternative.  Nurtec (rimegepant) initially was approved for the treatment of acute migraine.  Following the placebo-controlled phase 3 study which demonstrated Nurtec to be effective for acute migraine treatment, there followed a 1 year safety study wherein all participating patients were given Nurtec (no placebo) to use as needed for headache.  That study demonstrated Nurtec to be safe, well-tolerated and durable as an acute migraine treatment over a period of 1 year.  Even more interesting, patients who initially were taking Nurtec at a relatively high frequency to treat their migraine episodes experienced a progressive reduction in headache frequency.

In other words, along with helping relieve or eliminate the headache being treated acutely, Nurtec appeared to exert a “downstream” effect, reducing overall headache frequency in a manner not dissimilar from that seen when conventional migraine prevention therapies are administered on a scheduled basis.  This led to a large-scale, placebo-controlled trial which demonstrated that Nurtec was effective in reducing migraine frequency when taken on a scheduled (every other day) basis.  With the FDA’s approval of its use for migraine prevention in June of this year, Nurtec became the first medication to be indicated for both the acute and preventive treatment of migraine.

But maybe you don’t want to take any prevention therapy on a regular basis.  Given the results from the Nurtec safety study described in the previous paragraph, you may get a “two-fer” from as needed use of Nurtec, with both headache relief at the time you take the drug and a subsequent reduction in the likelihood it will be followed by another migraine episode.  Or maybe you have frequent migraine episodes only at certain times, like the days just before and during menses.  During those “high risk for migraine” times it may make sense to administer Nurtec on a scheduled basis, reverting to as needed use after that time passes.

In closing, it should be said that Nurtec quite likely is not the only medication used for acute migraine treatment that also has a “downstream” effect of reducing subsequent migraine frequency.  Treating acute migraine early, avoiding prolonged episodes of severe migraine headache and thus keeping the sensitivity of migraine’s biologic circuitry at a low level may result in an overall reduction in migraine burden.  If true, this serves as yet another good reason to treat acute migraine episodes aggressively.

Never miss an issue, subscribe to our email newsletter today!