Does more options for migraine treatment mean more options for general practice, or just another headache?

Another headline just last week put migraines back into the news again, when NICE’s draft guidance on Atogepant was published. Treatment of migraine is one of the areas that has evolved the most in recent years, and some of you reading this will – like me – remember when triptans were the big new kid on the block, the first drug designed specifically for migraines, after years of painkillers, beta blockers and pizotifen. In the last 4 years we have had two new classes of drug to treat migraine, both targeting CRGP. What is CRGP? It’s Calcitonin gene-related peptide, a type of protein produced by the body. When CRGP builds up in the nervous system, it triggers receptors which open up pain pathways and the migraine badness starts…

The 2 new drugs try to stop this in different ways. CRGP monoclonal antibodies (CRGP MABS) target either the CGRP itself, or its receptors, to stop it building up and triggering the pain pathways. CRGP receptor antagonists (GEPANTS) work by binding to the CGRP receptors to stop the pain pathways opening. Atogepant is the latest of the GEPANTS to hit the headlines, and it’s largely because of the extra options it gives us to manage migraine. 

While the CRGP MABS are injectable, Atogepant and the earlier GEPANT Rimegepant, can be taken orally. They can be used either in a similar way to triptans, as soon as an attack starts, or they can be taken regularly for prophylaxis. Atogepant has been placed by NICE in a similar group with other secondary care-initiated treatments for migraine. Patients need to have at least 4 migraine days a month and have tried 3 other preventative medications before Atogepant can be used, with a 12-week initial treatment period advised. Success is defined by NICE as at least a 50% reduction in episodic migraine, and at least a 30% reduction in chronic migraine. For patients who are on their 4^th line treatment option, those numbers would make a significant different to their quality of life. 

As is common with newer drugs, there is a commercial arrangement around the pricing of Atogepant. However, we know that the CRGP MABS cost around £385-450 a month. Rimegepant is around £180 a month. We don’t know the details of the NHS cost for Atogepant yet, but it’s likely to be a similar price given they are manufactured by two different drug companies.  While it’s definitely not cheap, it’s less than half the price of the other specialist drug options in the same treatment stage for a condition with a high disease burden affecting mostly working adults, and women predominantly.

Neither one of the GEPANTS will be coming to an FP10 near you just yet, but they will at some point. While they remain specialist initiated, both GEPANTs have been mentioned as being suitable for either shared care or initiation in primary care. For now, our role is to work through the steps in the guidance when we are managing a patient with migraine, making sure we move onto the next stage of treatment options if things aren’t improving. If your patient is needing prophylaxis and has tried 3 preventative therapies without success, it’s time for a referral. The SIGN guidance from 2023 is the most up to date migraine guideline at the moment, with SIGN’s usual clear quick reference guide and excellent flowchart. Migraine buddy is a detailed app for patients who find it easiest to keep track of things on their phone, but the Migraine Trust also has a headache diary template available. For more information, the British Associations for the Study of Headache (BASH) website has some great GP specific material; the Migraine Trust offers support for affected patients