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Update: October 4, 2021

1. Atogepant, to be marketed under the brand name Qulipta, an oral CGRP receptor antagonist used for episodic migraine prophylaxis, has been approved by the FDA.  It is the second oral option in the CGRP receptor blocker class for this indication.  Data demonstrate that the drug may decrease migraine frequency over a 12 week period.  The most common adverse events in clinical trials included constipation, fatigue and nausea. Dose adjustments are recommended for individuals receiving moderate to strong CYP34A inducers, strong CYP34a inhibitors, and OATP inhibitors as well as those with severe renal impairment.  The drug will be supplied in 10mg, 30mg and 60mg strengths.
   
   
2. Trudhesa is a newly approved formulation of dihydroergotamine mesylate.  While dihydroergotamine has been available as a nasal spray for some time, this formulation is given via a novel inhaler, referred to as a POD, or precision olfactory delivery device.  This device is intended to reach higher up into the nasal canal leading to greater efficacy.  It is used for the treatment of acute migraine.  Unlike other medications that are supposed to be used at the first sign of migraine, Trudhesa appears to work at any point during the headache.  Pain relief is often experienced within 15 minutes of use, and pain freedom may last up to 2 days after a single dose.  The total dose is 1.45mg split between both nostrils (one spray in each).  Dosing may be repeated in 1 hour if necessary, but no more than 3 doses should be administered in a 7 day period, and no more than 2 doses in one day.  Contraindications are the same as other dihydroergotamine products (history of ischemic disease, co-administration with a strong CYP34A inhibitor, uncontrolled HTN, severe liver or kidney disease, and use of a triptan or other ergotamine within a 24 hour period).  As of now, it is only available from 2 specialty pharmacies.
   
   
3. Aimovig (erenumab) has a new safety signal that has emerged.  The drug may induce new onset HTN (especially if there are risk factors) or make pre-existing HTN worse.  Some patients have needed to be treated with antihypertensives, and in rare cases hospitalization has been required.  Usually, onset of HTN happens within 7 days of the first dose, but occasionally the reaction has been delayed.  Ongoing monitoring for elevated blood pressure is recommended for anyone on erenumab for migraine prophylaxis.
   
   

Update: June 21, 2021

• In addition to its approval for acute migraine pain, rimegepant (Nurtec® ODT) was approved for migraine prophylaxis by the FDA on May 27, 2021
  • Rimegepant is the only medication approved for both acute migraine and migraine prevention
  • The preventive dose of rimegepant is 75 mg every other day, while the dose for acute migraine pain remains 75 mg by mouth, every day as needed for migraine headache pain
  • If a patient has a migraine on a day when rimegepant has already been taken, a non-CGRP active medication should be used to treat the headache
  • It is recommended that rimegepant be limited to a maximum of 18 doses per month regardless of indication