Title: Rimegepant for treating or preventing migraine [ID1539]
Funder: Department of Health and Social Care

Abstract: Migraine is primarily a headache disorder manifesting as recurring attacks usually lasting between 4 and 72 hours involving throbbing head pain of moderate to severe intensity. It is often accompanied by nausea, sometimes vomiting, sensitivity to light, sensitivity to sounds, and/or other sensory stimuli. Migraine can have significant impacts on quality of life and ability to carry out normal activities. Some people can have warning symptoms called an aura, before the start of a headache. Factors that can trigger attacks in people susceptible to migraines include stress, change in sleep pattern, overtiredness, menstruation, consumption of caffeine or alcohol, climatic conditions and use of visual display units._x000D_ _x000D_ Migraine is on a continuum, and it is possible for people to move between episodic and chronic migraine:_x000D_ _x000D_ • Episodic migraine is defined as the occurrence of headaches on less than 15 days per month_x000D_ _x000D_ • Chronic migraine is defined by the International Classification of Headache Disorders 3rd edition (ICHD-3)[1]. It is described as headache occurring on 15 or more days a month for more than 3 months, which, on at least 8 days a month, has the features of migraine headache._x000D_ _x000D_ It is estimated that there are 190,000 migraine attacks experienced every day in England[2]. Prevalence has been reported to be 5-25% in women and 2-10% in men[2]. There are 3 broad approaches to managing migraine: lifestyle and trigger management, acute treatments and preventive treatments. _x000D_ _x000D_ Treatments for acute migraine attacks include analgesics, triptans and anti-emetics. NICE clinical guideline 150 and the NICE pathway on the management of migraine (with or without aura) recommend an oral triptan with either a nonsteroidal anti-inflammatory drug (NSAID) or paracetamol, taking into account patient preferences, comorbidities and the risk of adverse events. For people who prefer to take only one drug, monotherapy with an oral triptan, NSAID, high-dose aspirin or paracetamol should be considered. Anti-emetics should be considered in addition to other acute migraine treatment even in the absence of nausea and vomiting._x000D_ _x000D_ Preventive treatment of migraines can take many forms including nutritional supplements, lifestyle alterations such as increased exercise and avoidance of migraine triggers. It can also include medications, which are generally considered for people depending on their disease burden and frequency of attacks. NICE clinical guideline 150 recommends offering topiramate or propranolol, and considering amitriptyline, for preventing migraine according to the person’s preference, comorbidities and risk of adverse events. _x000D_ _x000D_ NICE technology appraisal guidance 682 recommends erenumab for preventing migraine in adults who experience 4 or more migraine days per month and at least 3 preventive drug treatments have failed. NICE technology appraisal guidance 659 recommends galcanezumab for preventing migraine in adults who experience 4 or more migraine days per month and at least 3 preventive drug treatments have failed. NICE technology appraisal guidance 631 recommends fremanezumab for preventing migraine in adults if the migraine is chronic and at least 3 preventive drug treatments have failed. NICE technology appraisal guidance 260 recommends botulinum toxin type A for preventing headaches in adults with chronic migraine that has not responded to at least 3 prior pharmacological prophylaxis therapies and whose condition is appropriately managed for medication overuse._x000D_ _x000D_ References_x000D_ 1. The International Headache Society. International Classification of Headache Disorders 3rd edition (ICHD-3). Accessed May 2021._x000D_ 2. Steiner TJ et al. The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity. Cephalalgia. 2003;23(7):519-527.

Lay abstract: To appraise the clinical and cost effectiveness of rimegepant within its marketing authorisation for treating or preventing migraine.

Research activity codes: 6.1 PHARMACEUTICALS
Health categories: NEUROLOGICAL