A recent pooled analysis of four randomized, placebo-controlled trials has further demonstrated the efficacy and safety of rimegepant (Nurtec ODT; Pfizer) in the acute treatment of migraine. The analysis, presented at the 2024 Migraine Trust International Symposium, included data from 4,895 participants and showed statistically significant benefits over placebo across key efficacy endpoints. Rimegepant, a calcitonin gene-related peptide (CGRP) receptor antagonist, is approved for both acute and preventive treatment of migraine.
The pooled analysis included adults with at least a one-year history of migraine, experiencing 2-8 migraine attacks per month with moderate to severe pain intensity. These attacks typically lasted 4-72 hours if untreated. The co-primary endpoints were pain freedom and freedom from the most bothersome symptom at 2 hours post-dose.
Key Findings on Efficacy and Safety
The results indicated that rimegepant 75 mg once daily outperformed placebo on both co-primary endpoints. Specifically, 20.0% of patients on rimegepant achieved pain freedom at 2 hours compared to 11.8% on placebo (p<0.0001). Additionally, 40.2% of rimegepant-treated patients were free from their most bothersome symptom at 2 hours, versus 29.2% in the placebo group (p<0.0001).
Safety data revealed that rimegepant was well-tolerated, with nausea being the only adverse event reported in more than 1% of treated patients. Stewart Tepper, MD, vice president at the New England Institute for Neurology and Headache, emphasized the importance of these findings, highlighting the consistent efficacy, safety, and tolerability of rimegepant.
Optimizing Rimegepant Treatment
Dr. Tepper suggested three main strategies to maximize the benefits of rimegepant:
- Early Intervention: Patients should use rimegepant early in a migraine, even before pain begins, during the prodrome or aura phases, to increase the likelihood of achieving pain freedom.
- Consistent Use: Patients should treat each migraine headache with rimegepant, as more frequent use has been associated with fewer headaches.
- Flexibility: Patients can move between preventive and acute treatment with rimegepant, using it early for acute treatment and switching to every-other-day dosing for prevention during periods of vulnerability.
Impact on Rescue Medication Use
The analysis also showed a significant reduction in the use of rescue medication among rimegepant-treated patients. Only 15.5% of participants in the rimegepant group used rescue medication within 24 hours post-dose, compared with 28.9% in the placebo group. This reduction is crucial as it suggests that acute use of rimegepant may decrease the likelihood of transformation to medication overuse headache and chronic migraine.
The Future of CGRP-Targeting Treatments
Dr. Tepper anticipates an increase in the earlier use of CGRP-targeting treatments for both acute and preventive migraine treatment. He noted that older preventive medications often have high discontinuation rates due to side effects and limited efficacy, leading organizations like the American Headache Society to suggest CGRP-targeting treatments as first-line preventive options. Similarly, CGRP-targeting treatments are being considered as first-line options for acute migraine treatment when older treatments fail or are contraindicated. This shift is expected to lead to reductions in healthcare resource utilization and improvements in patient quality of life.
