What is the recommended treatment for a patient with a migraine attack, considering Ubrelvy (Ubrogepant) as an option?

Ubrelvy (Ubrogepant) for Acute Migraine Treatment

Ubrelvy (ubrogepant) 50-100 mg is an effective oral CGRP receptor antagonist for acute migraine treatment in adults, offering a safe alternative to triptans without cardiovascular contraindications, and should be taken as early as possible when pain is still mild for optimal efficacy. 1

Dosing and Administration

• The recommended dose is 50 mg or 100 mg taken orally as needed at migraine onset, with or without food. 1
• A second dose may be administered at least 2 hours after the initial dose if needed, with a maximum of 200 mg in 24 hours. 1
• Treatment when pain is mild (rather than moderate or severe) significantly increases efficacy: 2-hour pain freedom rates are 47-55% for mild pain versus 24-26% for moderate/severe pain. 2
• Limit use to no more than 8 migraine attacks per 30 days to prevent medication-overuse headache. 1

Clinical Positioning in Treatment Algorithm

• Ubrogepant is recommended as a first-line alternative when triptans are contraindicated or ineffective, particularly for patients with cardiovascular disease, uncontrolled hypertension, or cerebrovascular disease. 3
• Unlike triptans and ergot alkaloids, ubrogepant has no vasoconstriction and no cardiovascular contraindications. 3, 4
• For patients without triptan contraindications, the combination of triptan plus NSAID remains superior and represents the strongest first-line recommendation. 3

Efficacy Data

• In pivotal trials, 19-21% of patients achieved 2-hour pain freedom versus 12% with placebo (statistically significant). 5
• Freedom from most bothersome symptom at 2 hours occurred in 38% of patients versus 28% with placebo. 5
• Sustained pain relief from 2-24 hours and sustained pain freedom from 2-24 hours were demonstrated as secondary endpoints. 5

Safety Profile and Adverse Events

• The most common adverse events are nausea (2-4%), somnolence (2-4%), and dry mouth (0.4-4%), which are more frequent with the 100 mg dose. 1, 5
• Serious hypersensitivity reactions including anaphylaxis and dyspnea can occur within minutes, hours, or days after administration—discontinue immediately if this occurs. 1
• New-onset or worsening hypertension may occur; monitor blood pressure in at-risk patients. 1
• New-onset or worsening Raynaud's phenomenon may occur; discontinue if symptoms develop. 1

Contraindications and Drug Interactions

• Absolutely contraindicated with strong CYP3A4 inhibitors (ketoconazole, clarithromycin, itraconazole). 1
• Contraindicated in patients with history of serious hypersensitivity to ubrogepant. 1
• Avoid strong CYP3A4 inducers (phenytoin, rifampin, St. John's Wort) as they reduce ubrogepant exposure. 1
• Do not take a second dose within 24 hours if consuming grapefruit/grapefruit juice or taking moderate CYP3A4 inhibitors (verapamil, cyclosporine, ciprofloxacin, fluconazole, fluvoxamine). 1

Special Populations

• For severe hepatic or severe renal impairment: reduce dose to 50 mg, with a second 50 mg dose allowed at least 2 hours after initial dose if needed. 1
• Avoid use in patients with end-stage renal disease. 1
• Pregnancy Category: May cause fetal harm based on animal data; pregnancy registry available at 1-833-277-0206. 1
• Very small amounts pass into breast milk; discuss risks/benefits with breastfeeding patients. 1

Concomitant Use with Preventive CGRP Antagonists

• Ubrogepant can be safely used for acute treatment in patients taking atogepant for migraine prevention, with no new safety signals identified. 6
• The concomitant use of ubrogepant (up to 8 attacks per month) with daily atogepant 60 mg was well tolerated over 12 weeks. 6

Critical Pitfalls to Avoid

• Do not allow patients to exceed 2 days per week of acute medication use overall (including ubrogepant) to prevent medication-overuse headache. 3
• Do not use ubrogepant for migraine prevention—it is only indicated for acute treatment. 1
• Do not delay treatment until pain becomes severe; early treatment during mild pain more than doubles efficacy. 2
• Do not combine with strong CYP3A4 inhibitors due to absolute contraindication. 1