What is the recommended starting dose of Qulipta (atogepant) for a patient with episodic migraines?

Qulipta (Atogepant) Starting Dose

For episodic migraine, start Qulipta at 10 mg, 30 mg, or 60 mg once daily, with the choice depending on drug interactions and renal function; for chronic migraine, start at 60 mg once daily. 1

Episodic Migraine Dosing

The FDA-approved dosing for episodic migraine offers three options, all taken once daily with or without food 1:

• 10 mg once daily - Lowest dose option
• 30 mg once daily - Middle dose option
• 60 mg once daily - Highest dose option

All three doses demonstrated significant efficacy in reducing monthly migraine days (MMDs) over 12 weeks, with the 60 mg dose showing the greatest reduction (mean difference: -1.48 days compared to placebo). 2 The 2024 VA/DoD guidelines provide a weak recommendation for atogepant in episodic migraine prevention. 3

Chronic Migraine Dosing

For chronic migraine, the recommended starting dose is 60 mg once daily. 1 This is the only FDA-approved dose for chronic migraine and should not be adjusted downward unless required by drug interactions or renal impairment. 1

Mandatory Dose Adjustments

Drug Interactions

You must reduce the dose in the following scenarios 1:

• Strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, clarithromycin):

  • Episodic migraine: Reduce to 10 mg once daily
  • Chronic migraine: Avoid use entirely

• OATP inhibitors (e.g., rifampin, cyclosporine):

  • Episodic migraine: Use 10 mg or 30 mg once daily
  • Chronic migraine: Use 30 mg once daily

• CYP3A4 inducers (strong, moderate, or weak):

  • Episodic migraine: Use 30 mg or 60 mg once daily
  • Chronic migraine: Avoid use entirely

Renal Impairment

For severe renal impairment or end-stage renal disease (CrCl <30 mL/min) 1:

• Episodic migraine: Reduce to 10 mg once daily
• Chronic migraine: Avoid use entirely

Hepatic Impairment

Avoid atogepant in patients with severe hepatic impairment. 1

Clinical Context and Positioning

Atogepant is positioned as a preventive treatment option, not for acute migraine attacks. 3 The 2025 American College of Physicians guideline does not specifically address atogepant for acute treatment, focusing instead on triptans combined with NSAIDs or acetaminophen as first-line acute therapy. 3, 4

For patients requiring both preventive and acute treatment, atogepant 60 mg daily can be safely combined with ubrogepant 100 mg as needed for breakthrough attacks (up to 8 doses per 4-week interval), with no new safety signals identified in the TANDEM study. 5

Safety Considerations

The most common adverse events (≥5%) include 1:

• Nausea (6.1%)
• Constipation (5.3-28% in real-world studies)
• Fatigue/somnolence (6.5-16%)

Hypersensitivity reactions, including anaphylaxis and dyspnea, have been reported and can occur days after administration. 1 Atogepant is contraindicated in patients with prior hypersensitivity to the drug or its components. 1

Real-World Efficacy

In treatment-resistant chronic migraine patients with multiple prior preventive failures (median of 6 previous treatments), atogepant 60 mg daily reduced MMDs by 7.1 days at 24 weeks, with 53% achieving ≥50% reduction in MMDs. 6 Notably, 60% of chronic migraine patients converted to episodic migraine. 6 Even among patients who failed prior CGRP monoclonal antibodies, 47% still achieved ≥50% reduction in MMDs. 6

Common Pitfalls to Avoid

• Do not start chronic migraine patients at doses lower than 60 mg unless drug interactions or severe renal impairment mandate dose reduction 1
• Do not use atogepant as an acute treatment - it is preventive therapy only 3
• Do not overlook drug interaction screening before prescribing, particularly for CYP3A4 inhibitors/inducers and OATP inhibitors 1
• Do not continue if hypersensitivity reactions occur - discontinue immediately and institute appropriate therapy 1