Can I add Qulipta (atogepant) to a patient's regimen who has well-controlled migraine pain with Ubrelvy (ubrogepant)?

Adding Qulipta to Ubrelvy for Migraine Management

Yes, you can add Qulipta (atogepant) as preventive therapy to a patient currently using Ubrelvy (ubrogepant) for acute migraine treatment. This combination has been specifically studied and proven safe and well-tolerated 1.

Evidence for Concomitant Use

The TANDEM study directly evaluated this exact clinical scenario and provides strong evidence supporting this approach:

• Participants took atogepant 60 mg once daily for prevention while using ubrogepant 100 mg as needed for breakthrough migraine attacks (up to 8 doses per 4-week interval) over 12 weeks 1
• The combination was safe and well-tolerated, with no new safety signals identified and no increase in adverse events related to the number of ubrogepant doses taken 1
• Only 9.9% of participants discontinued either medication due to adverse events during the entire treatment period 1
• The most common adverse events were COVID-19 (3.2%), fatigue (1.4%), nausea (0.9%), decreased appetite (0.9%), and constipation (0.9%) during the combination period 1

Clinical Rationale

This combination addresses two distinct therapeutic needs:

• Ubrelvy (ubrogepant) is a CGRP receptor antagonist approved for acute treatment of migraine with or without aura 2
• Qulipta (atogepant) is a CGRP receptor antagonist approved for preventive treatment of episodic migraine 2
• Both medications target the same CGRP pathway but serve different purposes—one for prevention, one for acute attacks 3

When to Consider Adding Prevention

Adding preventive therapy like Qulipta is warranted when episodic migraines occur frequently or acute treatment alone does not provide adequate response 2. Current guidelines support this approach:

• The 2023 VA/DoD guidelines suggest atogepant for prevention of episodic migraine (weak for recommendation) 2
• The 2025 American College of Physicians guidelines recommend considering preventive medications when patients are adversely affected by migraine on ≥2 days per month despite optimized acute treatment 4

Dosing Recommendations

For the combination therapy:

• Atogepant (Qulipta): 60 mg once daily 1
• Ubrogepant (Ubrelvy): 100 mg as needed for breakthrough attacks, up to 8 doses per 4-week interval 1
• Maximum ubrogepant dose is 200 mg within 48 hours 5

Important Safety Considerations

Monitor for medication overuse headache:

• The threshold for medication overuse headache with CGRP antagonists is ≥10 days per month 2
• If the patient is using Ubrelvy frequently enough to warrant prevention, this combination helps reduce acute medication use 1

Contraindications and precautions:

• Do not use Qulipta in patients with previous allergic reactions to atogepant 6
• Dose adjustments may be needed with strong CYP3A4 inhibitors or inducers 6
• Avoid grapefruit juice with Qulipta 6
• Both medications should be avoided in end-stage renal disease 7

Assess efficacy after 3-6 months of preventive treatment 4. Consider pausing preventive treatment after 6-12 months of success to assess continued need 4.

Cost Considerations

Be aware that both medications are expensive:

• Atogepant (Qulipta) has an annualized wholesale acquisition cost of approximately $4,959-$5,994 2
• This is substantially higher than traditional preventive options like beta-blockers ($123-$393), amitriptyline ($67), or valproate ($274) 2
• However, if traditional preventives have failed or are contraindicated, CGRP-targeted therapies represent appropriate second-line options 4

Common Pitfalls to Avoid

• Do not abandon preventive treatment prematurely—efficacy should only be assessed after 3-6 months, not weeks 4
• Do not overlook drug interactions—both medications can interact with CYP3A4 inhibitors/inducers requiring dose adjustments 6
• Do not use in pregnancy—limited safety data exists for both medications in pregnancy 4, 6