Rimegepant somewhat effective for acute migraine (NNT = 13)

Reference

Lipton RB, Croop R, Stock EG, et al. Rimegepant, an oral calcitonin gene–related peptide receptor antagonist, for migraine. N Engl J Med 2019;381(2):142-149.

Synopsis

Rimegepant belongs to a new class of "gepants" that target a peptide thought to play a role in the pathogenesis of migraine pain. The authors play up the many harms and deficiencies of triptans in their introduction and the need for an alternative (the manufacturer has even started a public relations campaign called "Demand More" in advance of expected FDA approval). I recall being told that triptans were a veritable miracle cure when they were first introduced. Oh, how things change. In this study, 1186 adults with at least a one-year history of migraine, the onset of migraines before age 50, and 2 to 8 moderate/severe migraines per month were randomized to receive a single dose of rimegepant 75 mg or matching placebo. The manufacturer funded and designed the study, collected the data, did the data management and analysis, and even wrote the manuscript. Patients with substance use disorder or any "unstable medical condition" were excluded. The mean age of participants was 41 years, 89% were women, 74% were white, and they had a mean of 4.6 migraines per month. Groups were balanced at the start of the study, and analysis was by intention to treat. The primary outcome was freedom from pain at 2 hours, and was more likely in the treatment group (19.6% vs 12.0%; P < .001; NNT = 13). A second primary outcome of freedom from the most bothersome symptom (most commonly photophobia) was also more likely with active treatment (37.6% vs 25.2%; P < .001; NNT = 8). Sustained pain relief at 24 hours and the need for rescue medications were also better with active treatment. Adverse events were uncommon.