CGRP Antagonists (Gepants):
- Ubrogepant (Ubrelya): Approved for acute treatment; blocks CGRP receptor.
- Rimegepant (Nurtec ODT): Approved for both acute and preventive treatment; also blocks CGRP receptor.
- Atogepant (Qulipta): Approved for preventive treatment; blocks CGRP receptor.
- Rationale: CGRP antagonists target the calcitonin gene-related peptide (CGRP) pathway, which is implicated in migraine pathogenesis. They offer a novel mechanism distinct from traditional therapies like triptans.
- Ditans (Ditans):
- Lasmiditan (Reyvow): Approved for acute treatment; acts as a serotonin (5-HT1F) receptor agonist.
- Rationale: Ditans provide an alternative for patients who do not tolerate or respond to triptans, with a different receptor profile.
- Monoclonal Antibodies (CGRP mAbs):
- Erenumab (Aimovig): Preventive treatment; blocks CGRP receptor.
- Fremanezumab (Ajovy): Preventive treatment; blocks CGRP ligand.
- Galcanezumab (Emgality): Preventive treatment; blocks CGRP ligand.
- Rationale: These therapies target the CGRP pathway, offering long-acting prevention with fewer systemic side effects compared to oral medications.
- Dihydroergotamine (DHE) Inhalation (Inbrel):
- Approved for acute treatment; acts as a mixed 5-HT1B/1D/1F receptor agonist.
- Rationale: Provides an alternative for acute treatment, particularly for patients with refractory migraine.
Key Considerations:
- Efficacy: CGRP antagonists and mAbs show strong evidence in clinical trials for both acute and preventive treatment.
- Safety: Generally well-tolerated; ditans may cause dizziness, while CGRP mAbs have rare risks of constipation or hypertension.
- Guidelines: AHS/ANM guidelines recommend CGRP antagonists and mAbs as first-line options for patients with contraindications or poor response to triptans.