What is the preferred treatment between Ubrelvy (ubrogepant) and Nurtec (rimegepant) for acute migraine attacks?

Ubrelvy vs. Nurtec for Acute Migraine Treatment

Based on the most recent evidence, rimegepant (Nurtec) is slightly more effective than ubrogepant (Ubrelvy) for acute migraine treatment, with a lower number needed to treat (NNT) of 9 compared to 12 for achieving pain freedom at two hours. 1

Efficacy Comparison

Both medications are CGRP receptor antagonists (gepants) approved for the acute treatment of migraine with or without aura in adults. When comparing their effectiveness:

• Rimegepant (Nurtec):

  • NNT of 9 for achieving pain freedom at 2 hours 1
  • Orally disintegrating tablet formulation (may be beneficial for patients with nausea)

• Ubrogepant (Ubrelvy):

  • NNT of 12 for achieving pain freedom at 2 hours 1
  • Available in 50mg and 100mg tablets 2
  • Demonstrated efficacy in multiple phase III trials (ACHIEVE I and ACHIEVE II) 3, 4
  • Pain freedom at 2 hours: 20.5% vs. 13.0% for placebo 3
  • Absence of most bothersome symptom at 2 hours: 38.7% vs. 27.6% for placebo 3

Safety and Tolerability

Both medications have favorable safety profiles:

• Ubrogepant:

  • Most common adverse events: nausea (1.9%) and dizziness (1.4-2.1%) 3, 4
  • No serious adverse events related to treatment in clinical trials 3
  • Free from hepatotoxicity at therapeutic doses 2
  • Maximum dose of 200mg within 48 hours 2

• Both medications:

  • Well-tolerated with minimal cardiovascular risk 1
  • Minimal potential for medication-overuse headache 1

Clinical Context and Positioning

According to current guidelines, CGRP antagonists (gepants) such as rimegepant and ubrogepant are recommended options for patients who:

• Don't respond to or tolerate triptans 5
• Have contraindications to triptans
• Experience only partial effectiveness with other acute treatments 1

Additional Considerations

• Ubrogepant has also shown efficacy when administered during the prodrome phase of migraine, potentially preventing progression to moderate/severe headache 6
• Both medications effectively address not only pain but also associated symptoms like nausea, photophobia, and phonophobia 2, 3

Treatment Algorithm

1. First-line acute treatment options:

   • Oral triptans (sumatriptan, rizatriptan, eletriptan) with or without acetaminophen 5
   • NSAIDs (ibuprofen 400-800mg, naproxen sodium 500-550mg) for mild to moderate attacks 5

2. For patients who fail first-line treatments or have contraindications:

   • Consider CGRP antagonists (gepants) 5
   • Rimegepant preferred over ubrogepant based on lower NNT 1

3. Limit use of all acute treatments to 2-3 days/week to prevent medication overuse headache 5

Pitfalls and Caveats

• Neither medication is indicated for migraine prevention (only for acute treatment) 2
• Maximum dosing limits should be observed (ubrogepant: 200mg within 48 hours) 2
• Monitor for common side effects like nausea and dizziness
• Consider cost and insurance coverage, as these newer medications may be more expensive than traditional options