Ubrogepant Does Not Need to Be Held Prior to Anesthesia
Ubrogepant can be continued preoperatively, including on the day of surgery, as there are no specific anesthesia-related contraindications or drug interactions that require holding this medication.
Rationale Based on Available Evidence
The 2021 Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement provides clear guidance on perioperative management of migraine medications but does not include ubrogepant or other gepants (CGRP receptor antagonists) in their list of medications requiring preoperative discontinuation 1.
Key Distinctions from Other Migraine Medications
Triptans require holding on the day of surgery due to theoretical concerns about serotonin syndrome risk and drug-drug interactions with perioperative medications, despite their different mechanism of action 1. In contrast, ubrogepant works exclusively through CGRP receptor antagonism without affecting serotonin pathways 2.
Ergotamine must be held at least 2 days prior to operation because it causes prolonged vasoconstriction beyond its pharmacological duration, can precipitate myocardial ischemia, and has severe hypertensive interactions with local anesthetics containing epinephrine 1.
Why Ubrogepant Is Safe Perioperatively
No cardiovascular adverse effects: Unlike ergotamine and triptans, CGRP receptor antagonists like ubrogepant are free from cardiovascular adverse effects 1
Favorable safety profile: The most common adverse events with ubrogepant are nausea (2.0-4.1%), somnolence, and dry mouth—none of which create significant anesthesia concerns 3, 4
No significant drug interactions: Ubrogepant's mechanism as a small-molecule CGRP receptor antagonist does not involve the metabolic pathways (MAO-A, CYP3A4, CYP2D6, CYP1A2) that create perioperative concerns with triptans 1, 2
No hepatotoxicity at therapeutic doses: Unlike earlier gepants, ubrogepant is free from hepatotoxicity, eliminating concerns about perioperative liver stress 5
Clinical Implications
Continue ubrogepant through the day of surgery if the patient has been taking it for acute migraine treatment 1. There is no evidence suggesting that ubrogepant interferes with anesthetic agents, causes hemodynamic instability, or increases perioperative complications 6, 3.
Important Caveats
Pregnancy considerations: While not directly related to anesthesia, ubrogepant should be avoided in pregnant patients due to insufficient safety data, though this is a separate concern from perioperative management 7
Renal disease: Patients with end-stage renal disease should avoid ubrogepant, but this is a general contraindication rather than an anesthesia-specific concern 6
Concomitant use with preventive gepants: The safety of using ubrogepant acutely while on preventive CGRP antagonists (like atogepant) has been established, showing no increased adverse events 8