When you have migraine, treatment usually falls into two general categories: acute medicine you take during an attack or preventive medicine you take regularly to reduce how often attacks happen.
“Gepants” (pronounced “gee-pants”) are part of a new group of migraine drugs that has expanded both sides of that equation, since some are used during an attack, some are used for prevention, and one can do both.
That broader role — and a better side effect profile than other treatments — is part of the appeal, says William Jarrard, MD, an assistant professor of medicine and neurologist at the Medical University of South Carolina in Charleston. “These newer medications, including gepants, have truly been game changers in migraine treatment,” says Dr. Jarrard.
What Are Gepants?
Gepants are part of a class of migraine medicines called CGRP inhibitors. CGRP stands for calcitonin gene-related peptide, a molecule involved in migraine pain. During a migraine attack, extra CGRP can amplify pain signals and make symptoms more severe or longer lasting. Gepants block that CGRP pathway.
That's what makes gepants “a great treatment for migraine,” says Daod Pak, MD, a neurologist at Stony Brook Medicine on Long Island, New York.
They also come in several forms, including tablets, dissolving tablets, and nasal spray, so they are easier to match to a person’s symptoms and preferences, says Dr. Pak.
Approved gepants include these forms:
ubrogepant (Ubrelvy) for acute treatment
rimegepant (Nurtec ODT) for acute treatment and prevention
zavegepant (Zavzpret) as a nasal spray for acute treatment
atogepant (Qulipta) for prevention only
Not every gepant plays the same role in migraine treatment. Some are used to stop a migraine after it starts, while others help prevent attacks from happening as often, says Pak.
How Do Gepants Compare to Other Acute Treatments?
In addition to gepants, other options for treating a migraine attack include over-the-counter pain relievers, triptans, dihydroergotamine, and anti-nausea medicines.
No single medication suits everyone with migraine; treatment depends on different factors, including symptoms, medical history, other medications being used, and access.
Gepants are a strong alternative to older migraine medicines, says Pak. “They are considered when patients have not responded to more traditional medications, such as triptans,” he says.
They are also an option when people can’t take triptans, such as people who have had a heart attack or stroke, or those who have had significant side effects on other migraine medications, he says.
“Gepants can also be considered a first-line treatment, depending on the patient,” says Pak.
Efficacy
For many people, gepants effectively stop a migraine attack, even in people who haven’t had success with other acute treatments.
Ubrogepant In a 52-week extension study, ubrogepant led to freedom from pain after two hours in 23 to 25 percent of attacks and pain relief after two hours in about 65 to 68 percent of attacks. It worked even better when taken early — while pain was still mild — with two-hour pain freedom rising to about 51 to 54 percent.
Rimegepant Rimegepant has shown sustained efficacy as an acute treatment in long-term studies. A review also found that it worked about as well in people with prior triptan failure as it did in current triptan users and people who had never used a triptan, based on two-hour pain freedom and relief of the most bothersome symptom.
Zavegepant The nasal spray zavegepant can relieve migraine pain within two hours and may keep helping for up to 48 hours. Nasal delivery may be especially useful for people who have nausea or vomiting during an attack, when taking a pill can be harder.
Side Effects
Oral gepants can cause dry mouth, nausea, and sleepiness, while zavegepant can cause taste changes, nasal discomfort, and throat irritation.
Cost
Depending on your prescription insurance coverage, cost may be an issue. Several triptans are available as generics, which tend to be much less expensive than brand-name drugs. Gepants are newer and may still come with insurance hurdles or high copays.
“Traditionally, people had to try other therapies first before gepants were approved by their insurance,” says Jarrard. However, that has started to change, and some insurance plans are covering them without requiring other therapies first, he says.
“If you have a high copay, some of the manufacturers offer savings cards to help with the cost,” says Pak.
How Do Gepants Compare to Other Preventive Treatments?
Preventive migraine treatment has traditionally included drugs originally developed for other conditions, such as beta-blockers for blood pressure, anti-seizure medicines like topiramate, and antidepressants like amitriptyline.
Studies have found that gepants and anti-CGRP monoclonal antibodies — a type of CGRP inhibitor given by injection and used for prevention only — show the most consistent reduction in monthly migraine days, while older drugs, including topiramate and propranolol, offered more modest benefit and higher rates of adverse events. A review of studies totaling over 15,000 people concluded that CGRP-targeted therapies and gepants are effective first-line options for episodic migraine prevention.
The review found that gepants reduced monthly migraine days by about 3.6 to 4.4 days at 12 weeks. Older drugs, including topiramate and propranolol, also reduced migraine days, but side effects were more frequent and difficult to tolerate.
Drowsiness, brain fog, and weight gain are all relatively common with the older preventive medications, says Jarrard. Nausea, constipation, and fatigue were the most common side effects of gepants.
Cost and insurance concerns for gepants for preventive use are similar to the access barriers in acute migraine treatment.
Talking to Your Doctor About Trying Gepants
If your current medication is not providing relief or provides only partial relief, or if side effects are an issue, talk with your doctor, says Pak.
Gepants can be considered at several points in care, including at diagnosis, says Jarrard.
The more detailed you can be in describing your migraine attacks, the better. Experts suggest being ready to share the following information with your doctor:
How often your migraine attacks happen
How well your current medicine works
Whether you need repeat doses
How many doses of acute treatment you are taking per month
Any side effects you’ve had
Whether nausea or vomiting makes pills harder to take
What other medical conditions you have or other medications you’re taking, which might affect your migraine treatment options
“People with four or more migraine days a month may benefit from preventive treatment,” says Jarrard. Not only will reducing your headache days improve your ability to function but it can also reduce the likelihood of developing rebound headaches, which can happen if you take acute treatment too often, he says.
