1 Recommendations

1.1

Atogepant is recommended as an option for preventing migraine in adults who have at least 4 migraine days per month, only if at least 3 preventive medicines have failed.

1.2

Stop atogepant after 12 weeks if the frequency of migraines does not reduce by:

at least 50% in episodic migraine (defined as fewer than 15 headache days per month)
at least 30% in chronic migraine (defined as 15 or more headache days per month, with at least 8 of those having features of migraine).

1.3

If people with the condition and their healthcare professional consider atogepant to be 1 of a range of suitable treatments, after discussing the advantages and disadvantages of all the options, use the least expensive. Take account of administration costs, dosage, price per dose and commercial arrangements.

1.4

This recommendation is not intended to affect treatment with atogepant that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS healthcare professional consider it appropriate to stop.

Why the committee made these recommendations

For this evaluation, the company asked for atogepant to be considered only for people who have already had at least 3 preventive medicines that have not worked. This does not include everyone who atogepant is licensed for. Usual preventive medicines at this point include erenumab, fremanezumab, galcanezumab, eptinezumab, rimegepant (for episodic migraine only) or botulinum toxin type A (for chronic migraine only).

Clinical trial evidence shows that atogepant reduces monthly migraine days more than placebo, but there is no clinical trial evidence directly comparing it with other preventive medicines. The results from indirect comparisons are uncertain and it is unclear how well atogepant works compared with other preventive medicines for episodic or chronic migraine.

For episodic migraine, the most relevant comparator is rimegepant because it is also an oral preventive medicine. The most likely cost-effectiveness estimate for atogepant compared with rimegepant is within the range that NICE normally considers an acceptable use of NHS resources.

For chronic migraine, it is not clear whether atogepant is better or worse than the other preventive medicines, but it has lower costs. So, atogepant is recommended for preventing episodic and chronic migraine after 3 or more preventive medicines.