Rimegepant (NURTEC ODT) is the second gepant approved for the acute treatment of migraine headaches. It blocks the same CGRP pathway as the injectable monoclonal antibodies that are used for the prevention of migraine attacks (erenumab/Aimovig, fremanezumab/Ajovy, galcanezumab/Emgality, and eptinezumab/Vyepti). It follows the recent introduction of a similar drug that also blocks the CGRP receptor, ubrogepant (Ubrelvy).
Since there have been no head-to-head trials comparing these two gepants, it is had to say if one is better than the other. On average, they appear to be very similar, but this does not mean that they will be equally effective or cause the same side effects in a particular patient. We see this with triptans (drugs like sumatriptan, eletriptan, and other) – the top 5 show similar efficacy in trials, but some patients strongly prefer one over another.
One difference is that rimegepant is an orally disintegrating tablet and does not require water, while ubrogepant is taken with water. This makes rimegepant easier to take on the go and could be easier to take for patients with severe nausea. Another minor difference is that the dose of rimegepant is 75 mg that is taken once a day, while ubrogepant comes in 50 and 100 mg tablets and either dose can be repeated for up to 2 tablets a day. This can be both an advantage and a disadvantage. The instructions are simple for rimegepant – take one tablet once on the day you have a migraine (and the earlier you take any abortive drug the better). With ubrogepant the doctor has to decide whether to give 50 or 100 mg dose and the patient needs to be instructed to take a second dose on the same day (as soon as 2 hours after the first one) if the headache returns or does not completely resolve with the first dose. In clinical trials, this second dose did produce additional improvement.
The safety of rimegepant is as remarkable as that of ubrogepant and the preventive injectable monoclonal antibodies. Rimegepant caused nausea in 2% of patients compared with 0.4% of those on placebo and less than 1% developed a rash or temporary difficulty breathing.
