New Migraine Treatments UK

Migraine treatments have come a long way since triptans, which have been clinically available since the 90s. The discovery of new therapies which target CGRP receptors have paved the way towards a novel treatment option which can treat the cause of migraine rather than just the symptoms.

The most significant step forward is the discovery of the -gepant family, such as Vydura. Containing the drug rimegepant, Vydura is the first medicine licensed in the UK both to treat an active migraine but also to prevent future attacks. Approved by NICE in 2023, Vydura offers a needle-free alternative to older preventative treatments.

Vydura (Rimegepant) - The UK's First Gepant

Vydura as the UK’s first -gepant, is a breakthrough in that it is the first oral drug available which can both treat and prevent migraines. Additionally, as it blocks the CGRP receptor without constricting blood vessels, it can safely be used by patients with underlying heart conditions.

Vydura was granted MHRA approval in 2022 with NICE following in 2023/2024 for NHS use. To obtain on the NHS, patients must have already tried and failed with 2 to 3 triptans. However, it can be accessed privately from Quick Meds to patients who have a formal migraine diagnosis.

CGRP Monoclonal Antibodies - Now Available on NHS

Before the -gepant drugs were approved, the only preventative treatments available were CGRP monoclonal antibodies (mAbs) These are injectable treatments, usually used once a month, with some administered once every three months.

The currently approved mAbs are Erenumab (Aimovig), Fremanezumab (Ajovy), Galcanezumab (Emgality) and Eptinezumab (Vyepti). NHS access is limited to prevent migraines in adults who:

• Suffer from 4 or more migraines per month

• Have tried at least 3 preventative treatments which have not worked/not tolerated.

These specialist treatments can only be prescribed following a referral to a consultant neurologist and are not usually prescribed by the GP. This is where the new -gepants offer an advantage as they are preventative treatments which can be prescribed by your GP and privately.

What About Atogepant (Aquipta)?

Atogepant is a newer -gepant medication which gained NICE approval in 2024. Differences between this and rimegepant are highlighted below:

Rimegepant can offer flexibility in that if a breakthrough migraine is experienced whilst using for prevention (on alternate days) an extra wafer can be taken on the ‘off’ days so long as you do not exceed 75mg in 24-hours.

Atogepant is taken every day, with studies suggesting it may result in greater reduction in monthly migraines.

NICE recommends:

• Rimegepant for episodic migraines (less than 15 headaches per month)

• Atogepant for episodic and chronic migraines (more than 15 headache per month with at least 8 being migraines)

Ditans: Lasmiditan - Is It Available in the UK?

Lasmiditan is the first of a new class of medications called Ditans. These activate the 5-HT1F receptors, (triptans activate 5-HT1B and 1D receptors).

By turning on these specific f-type receptors, they stop nerves from transmitting pain and prevent the release of CGRP. These 1F are not found on blood vessels and therefore lasmiditan do not cause vasoconstriction.

Lasmiditan was approved by the FDA in 2019, but as of 2022, is not being pursued for approval by the MHRA in the UK. NICE has suspended development of Lasmiditan in the UK due to the low likelihood of being cost effective.

Neuromodulation Devices

Neuromodulation devices provide drug-free migraine relief by using electrical or magnetic impulses to stimulate nerves and block pain signals. They are a viable alternative to patients who cannot take medication due to contraindications.

Cefaly is a device applied to the forehead. This can be used both to treat and prevent a migraine. It produces electrical impulses which stimulate a nerve above the eye (the trigeminal nerve). This can be purchased privately from the manufacturers website.

Another device called gammaCore, is applied to both sides of the neck, and delivers an electoral stimulation to the vagus nerve to block pain signals. This device is available on the NHS but for cluster headaches. For migraine, it usually requires private funding.

What's Coming Next? Research Pipeline

The migraine treatment landscape is moving towards treatment options that provide convenient delivery systems. Whilst CGRP blockers like atogepant and rimegepant are promising, researchers are focusing on new treatments to fill the gap for those who don’t respond to currently available treatments.

The next generation -gepant drug is Zavegepent, available as a nasal spray, offering convenience to those who suffer from severe nausea or vomiting and struggle with tablets. Approved by the FDA in 2023, it is moving through the final stages of UK review.

Other options in early development stages include oral CGRP antibody formulations. Current mAbs are injectable-only. Research is underway to develop a tablet form which works as good but which offers greater flexibility - a once daily tablet can be stopped if needed due to side effects.