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

Ubrelvy vs. Nurtec for Acute Migraine Treatment

Both Ubrelvy (ubrogepant) and Nurtec (rimegepant) are effective CGRP antagonists (gepants) for acute migraine treatment, but neither is definitively superior to the other based on current evidence, and both are recommended as "weak for" options by clinical guidelines. 1, 2

Efficacy Comparison

• Both medications are FDA-approved calcitonin gene-related peptide (CGRP) receptor antagonists for acute migraine treatment
• Both medications show similar efficacy profiles:
  • Ubrogepant: Pain freedom at 2 hours in 20.5% vs 13.0% for placebo 3
  • Both have a similar number needed to treat (NNT) of approximately 13 for pain freedom at 2 hours 1
  • Neither medication has demonstrated superiority over the other in head-to-head trials

Clinical Guideline Recommendations

• The 2024 VA/DoD Clinical Practice Guideline gives a "weak for" recommendation for both ubrogepant and rimegepant for acute migraine treatment 1
• The 2025 American College of Physicians guideline notes that CGRP antagonists-gepants may have lower likelihood of pain freedom and relief at 2 hours compared to the combination of a triptan and an NSAID (low-certainty evidence) 1
• Guidelines suggest that first-line treatments for acute migraine should include:
  • NSAIDs (ibuprofen, naproxen)
  • Acetaminophen
  • Combination of NSAID + acetaminophen
  • Triptan + NSAID combination 2

Dosing Considerations

• Nurtec ODT: 75mg taken at onset of migraine, maximum of 75mg once per 24-hour period 2
• Ubrogepant: Available as 50mg and 100mg tablets, with a maximum dose of 200mg within 48 hours 4

Safety and Tolerability

• Both medications have favorable safety profiles compared to triptans:
  • No cardiovascular contraindications
  • No significant hepatotoxicity reported in clinical trials 5
• Common adverse events for both medications include:
  • Nausea (approximately 2%)
  • Dizziness (1.4-2.1%) 6, 3

Practical Considerations

• Nurtec is available as an orally disintegrating tablet (ODT), which may be beneficial for patients with nausea
• Ubrogepant has been studied for treatment during the prodrome phase of migraine, showing efficacy 7
• Both medications should be limited to ≤10 days per month to prevent medication overuse headache 2

Important Caveats

• Cost considerations: Both medications have significantly higher costs compared to traditional migraine treatments, with annualized wholesale acquisition costs ranging from $4,959 to $5,994 1
• Neither medication should replace the recommended first-line combination therapy of a triptan with an NSAID when appropriate 1, 2
• Treatment should begin as soon as possible after migraine onset to optimize effectiveness 2
• Patients should be counseled about medication overuse headache risk when using these medications more than 10 days per month 2

In summary, while both Ubrelvy and Nurtec are effective options for acute migraine treatment, neither has demonstrated clear superiority over the other. The choice between them may depend on insurance coverage, patient preference for formulation (ODT vs tablet), and individual response to treatment.