Rimegepant for preventing migraine

1.1 Rimegepant is recommended as an option for preventing episodic migraine in adults who have at least 4 and fewer than 15 migraine attacks per month, only if at least 3 preventative treatments have not worked.

1.2 Stop rimegepant after 12 weeks of treatment if the frequency of migraine attacks does not reduce by at least 50%.

1.3 If people with the condition and their clinicians consider rimegepant 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 These recommendations are not intended to affect treatment with rimegepant that was started in the NHS before this guidance was published. People having treatment outside these recommendations may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.

Why the committee made these recommendations

The company proposed rimegepant for preventing episodic migraine after 3 or more treatments have not worked, which is narrower than the marketing authorisation. Usual treatments at this point include erenumab, fremanezumab or galcanezumab, which are injections. Rimegepant is an oral treatment, which may be preferred by some people.

Clinical trial evidence shows that rimegepant reduces monthly migraine days more than placebo. It has not been directly compared in a trial with erenumab, fremanezumab or galcanezumab, but indirect comparisons suggest that it is likely to be similar to or less effective than these.

Rimegepant is cost effective compared with 2 of the 3 usual treatments. So rimegepant is recommended for preventing migraine after 3 or more preventative treatments have not worked.