Concomitant Use of Acute and Preventive CGRP Antagonists for Migraine

A clinical report on the concomitant use of an acute and a preventive calcitonin gene-related peptide (CGRP) antagonist has been published in Neurology the medical journal of the American Academy of Neurology (AAN). The report documents brief concomitant treatment with the investigational agent, rimegepant (Biohaven, New Haven, CT), and erenumab (Aimovig; Amgen, Thousand Oaks, CA) in 2 women. Both of the women treated were participants in a long-term safety study (NCT03266588) of rimegepant (75 mg oral tablets at headache onset) for the acute treatment of migraine.   

As allowed by the study protocol, both women began treatment with erenumab (intramuscular injection monthly) after it was approved by the Food and Drug Administration (FDA). 

Both individuals treated had self-reported suboptimal responses to multiple medications for treatment of migraine over at least 2 decades. The first individual treated was age 44 and began using erenumab (70 mg/month) after 6 months of using rimegepant for acute treatment of migraine, which continued while using erenumab for prevention of migraine. The second individual, age 36, began erenumab (140 mg/month) after she had been using rimegepant for 60 days, and continued using both drugs as well. 

Both women found rimegepant effective for treating migraine attacks when they occurred but did not have reductions in migraine frequency. During a 30-day run-in period before starting rimegepant, these individuals had 10 and 22 attacks, respectively.

After 30 days of treatment with erenumab, a respective 46% and 41% reduction in migraine attacks occurred, and 16 breakthrough migraines occurred (7 in person 1 and 9 in person 2) and were all treated successfully with rimegepant. Both patients eliminated use of other acute headache treatments, including ibuprofen, caffeinated analgesics, injectable ketorolac, diphenhydramine while being treated with erenumab and rimegepant.

As noted, concomitmant treatment was brief, as it was ultimately decided that both individuals could not remain in the clinical trial for rimegepant while being treated with erenumab. No treatment-related adverse events were reported for either case during treatment with rimegepant alone or during concomitant treatment with both drugs.