P MIGRAINE X GEPANTS

 A

This 17-year-old girl with a 5-year history of migraine has experienced some improvement in her migraine frequency with better sleep, stress management, and regular exercise. She currently has 3-4 migraines per year, but ibuprofen has been ineffective for acute migraine treatment, and sumatriptan caused nausea and vomiting when tried. She is also on medications for anxiety and depression (fluoxetine), oral contraceptives, and methylphenidate for ADHD.

Key Points:

• Chronic migraine has improved significantly with lifestyle changes.

• The patient’s acute migraine treatment with ibuprofen is ineffective.

• She experienced nausea and vomiting with sumatriptan, a serotonin receptor agonist.

• The mother is asking about gepants (a newer class of medications for migraine treatment).

Differential Diagnosis:

The patient's presentation suggests chronic migraine that has significantly improved in frequency with lifestyle modifications but requires better acute management. Her history of nausea with sumatriptan suggests potential side effects, and her question about gepants suggests interest in alternative acute treatment options.

Gepants in Migraine Treatment:

Gepants are a newer class of calcitonin gene-related peptide (CGRP) receptor antagonists that have been shown to be effective for both acute and preventive treatment of migraine.

1. Mechanism of Action: Gepants work by blocking the CGRP receptor, which plays a key role in migraine pathophysiology, particularly in the dilation of blood vessels and transmission of pain in the brain.

2. Approved Medications:

   • Rimegepant (Nurtec ODT)

   • Ubrogepant (Ubrelvy)

   These are FDA-approved for acute treatment of migraine attacks. Rimegepant is also approved for migraine prevention.

3. Benefits of Gepants:

   • Gepants are generally well-tolerated and do not carry the same serotonin-related side effects (e.g., nausea, vomiting) that are seen with triptans, such as the reaction the patient had with sumatriptan.

   • No vasoconstriction: Unlike triptans, gepants do not cause vasoconstriction, making them safer for patients with certain cardiovascular conditions.

   • Rapid onset: Gepants work relatively quickly, providing migraine relief within 2 hours.

   • Lower side effect profile: They have a lower incidence of common migraine treatments’ side effects, such as nausea, dizziness, or somnolence.

4. Considerations:

   • Gepants can be expensive, which may affect accessibility, especially for adolescent patients.

   • They are typically considered second-line therapies after failure of NSAIDs and triptans.

   • They may be a good option for patients who cannot tolerate triptans or those with contraindications to their use (e.g., cardiovascular disease).

Treatment Strategy:

Given the patient's history of ineffective ibuprofen and nausea with sumatriptan, gepants may be a suitable alternative for acute migraine treatment.

1. Acute Treatment:

   • Gepants (e.g., rimegepant or ubrogepant) may be an appropriate first-line option for this patient.

   • These medications can be used on demand to treat acute migraine attacks.

2. Preventive Treatment:

   • Since her migraine frequency has decreased with lifestyle modifications, preventive treatment may not be needed at this point. However, if the frequency increases, CGRP inhibitors (e.g., rimegepant) or beta-blockers can be considered as preventive treatments.

   • Given her history of anxiety and depression, preventive treatments should be chosen carefully to avoid exacerbating her psychiatric symptoms.

3. Non-Pharmacologic Strategies:

   • Continuing stress management, exercise, and sleep hygiene will be important to maintaining her improved migraine frequency.

   • Biofeedback or cognitive behavioral therapy may also help in managing both her migraines and underlying anxiety and depression.

Conclusion:

The most appropriate next step in treating this patient's acute migraine episodes would be the use of gepants (e.g., rimegepant or ubrogepant). These medications are effective, well-tolerated, and do not cause the nausea and vomiting seen with sumatriptan. As her migraine frequency is low (3-4 times per year), preventive treatments may not be necessary at this time, but they should be considered if the frequency increases in the future. Non-pharmacologic strategies should continue as part of her overall migraine management plan.