We’re almost two months into the new year and the horizon is looking rather bright in terms of new options for migraine medications. Between patient advocacy efforts, Headache on the Hill, and the upcoming Migraine World Summit, there’s a lot of information to sort through and digest.
I’m personally on the eve of seeing my neurologist for the final time before I relocate and have to start the process all over again. However, there’s a lot to discuss in terms of what’s next before I go, starting with the new medications hitting the market.
In October of 2019, Reyvow (lasmiditan) was approved by the FDA.
In December of 2019, Ubrelvy (ubrogepant) was approved by the FDA.
Both Reyvow and Ubrelvy are intended to be used for the acute treatment of migraine attacks, and both are now available to be prescribed.
Just this February, Eptinezumab has been approved by the FDA for the preventative treatment of migraine.
Rumors have been circulating regarding costs, availability, and effectiveness of the new medications.
Before I get into my personal hopes and concerns, I want to give a brief overview of each new option.
Reyvow for the Acute Treatment of Migraine
Reyvow is the first and only approved medication of its kind – a new class of drugs called “ditans” which were heavily discussed in last year’s Migraine World Summit. These are options that would give individuals who are unable to take Triptans due to cardiovascular reasons a safe migraine abortive.
Reyvow is clear in it’s warning that you CANNOT drive or operate machinery for at least 8 hours after taking the medication, even if you feel well.
Risks and Side Effects:
- Medication Overuse Headache
- Serotonin Syndrome
- Sleepiness/Feeling Tired
Reyvow appears to have interactions with common migraine medications including Propranolol, Anti-Depressants, and Blood Pressure medications.
You are limited to one dose in a 24 hour period of time, as advised on the Reyvow website.
Important notes from clinical trials:
- 28-39% of individuals in the trial were pain free after two hours of taking Reyvow compared to the placebo, which had a success rate of 15-21%.
- 41-49% of individuals had freedom from their most bothersome symptom compared to 30-33% of those who received the placebo. The most noted symptoms were: sensitivity to light, sensitivity to sound, and nausea.
There is a savings card available directly from Lilly, allowing you to receive the medication for as low as $0 for 12 months. You can find it here. These savings are not available to people on Medicaid, Medicare, Medicare Part D, Medigap, DoD, VA, TRICARE®/CHAMPUS, or any state patient or pharmaceutical assistance program.
According to GoodRX, Reyvow can be purchased starting at $639 for the 50mg dose. This is for 8 pills, so approximately one month’s worth of medication.
According to Express Scripts, the mail order pharmacy I use with Tricare, the medication comes up as “covered” but it says “cannot price” the drug.
Ubrelvy for the Acute Treatment of Migraine
Ubrelvy is also one of the first of it’s kind. 2018 and 2019 saw the release of three CGRP targeted preventative treatments (Aimovig, Ajovy, and Emgality), and Ubrelvy is the first CGRP medication designed as an abortive treatment rather than preventative. This is the first gepant to reach the market, the other highly talked about release from last year’s Migraine World Summit.
Risks and Side Effects:
It is noted that you can take a second dose of Ubrelvy after two hours.
Important Notes from Clinical Trials:
- 1 in 5 individuals had total pain freedom after taking Ubrelvy.
- There are notes regarding a decrease in bothersome symptoms.
There is a savings card available directly from Allergan that allows you to receive the medication for $10 a month, or $1 a pill. You can find it here. Offer not valid for patients enrolled in Medicare, Medicaid, or other federal or state healthcare programs.
According to GoodRX, Ubrelvy can be purchased starting at $846 with an advertised retail price of over $1000. This is for 10 pills, which is one month’s worth of medication.
According to ExpressScripts, a coverage review is required to determine eligbility for the medication, however if approved the cost is $180 for a 90 day supply.
Eptinezumab for the Preventative Treatment of Migraine
Eptinezumab also known as Vyepti, will be the 4th CGRP preventative to hit the market with one noticeable difference: it will be administered via IV or infusion compared to the existing auto-injectibles. It will also be a quarterly infusion rather than a month to month dose.
Risks and Side Effects:
- Nasal passage swelling
- Hypersensitivity such as facial flushing
Important Notes from Clinical Trials:
- For Episodic patients, the average reduction in migraine days was 4.3 days, with an average of 8.6 migraine days prior to receiving the drug.
- 1/3 of Episodic patients had a 75% reduction in 4-12 weeks, with 1 in 5 patients having 100% reduction.
- For Chronic patients, the average reduction in migraine days was 8.2 days, with an average of 16.1 migraine days prior to receiving the drug.
- 33% of chronic patients had a reduction of 75% in migraine days, with 15% of patients have 100% reduction.
- The most notable observation is called a “rapid onset” of the medication with 52% of chronic migraine participants and 53.6% of episodic participants experiencing immediate improvements and migraine reduction after receiving the infusion.
It is predicted that Eptinezumab will hit the market with a $6900 yearly price tag – roughly $1725 per infusion. Due to it being an infusion, there will likely be costs and approval needed for the medication and the procedure similar to the pricing structure of Botox.
The drug has yet to actually hit the market, but savings cards will likely be available, however this will likely exclude those on government programs such as Medicare/Medicaid/Tricare.
What Does This Mean For Me?
All of the new drugs come with both curiosity and hesitation on my end. Between side effect concerns and accessibility hurdles there’s a lot to unpack.
First and foremost, having the drugs available is a great start but it is not a given that they can be accessed quickly, will provide relief in a timely manner, or will be long term solutions – so yes, you may see that new medications are “available” but new medications are always an uphill battle.
Reyvow is the medication I am most excited about. I will be asking for it tomorrow as I personally see the most potential benefit from it.
- It reminds me a lot of my existing migraine abortive (fioricet) in it’s lengthy list of impairing side effects.
- These side effects may prevent me from driving, but if this medication effectively aborts the attack, I could be more productive opening up the opportunity for work or education done remotely. Currently, fioricet’s side effects impair my abilities just as much as a migraine attack.
- The risk for medication overuse stands out as a red flag.
- The Reyvow website was the most put together and shared actual statistics from the clinical trials and I appreciate that transparency.
Ubrelvy also has piqued my interest, so I will be inquiring about it tomorrow as well.
- Most notably, as an abortive it is a much smaller amount of medication with a half life of 5-7 hours. This makes me more open to trying it than the preventative CGRPs.
- I had a severe reaction to Aimovig, the first CGRP to hit the market, and the risk of experiencing the same side effects has kept me from trying the other variations.
- The availability of information felt low, and the website wasn’t as transparent as Reyvow’s, keeping my confidence in it relatively low until more information from patient’s experiences are available.
Eptinezumab has me more concerned than hopeful. Having had such a severe reaction to a CGRP before, the idea of a quarterly infusion brings up concerns of how detrimental a severe reaction may be on a drug only being introduced every three months. It is interesting to see the half life is only 31 days with dosing every 90 days. This brings up the question as to why the dosing is spread out so far with the half life being similar to monthly CGRP’s like Aimovig. Will the medication begin to wear off before the next infusion, how long will effects from the medication last after discontinuing it?
- I believe this option may be great for people already having success on a CGRP who want a different method of administration, rather than a first line option for someone who has never tried one of the other three CGRPs.
- Infusions make the drug inaccessible to a vast portion of the population as it requires access to an infusion clinic.
For all three drugs, cost is also a huge factor. For the vast majority of patients, due to insurance requiring other medications be tried first and failed, people who are seeking these options are severely disabled by migraine. This means they often are not in a position where they have insurance through work – as they’ve most likely ceased working, or only work part time – or they receive benefits like SSI/SSDI excluding them from discount programs.
The next two years will be critical in examining these drugs to get a better picture of how effective they are in the real world. We have yet to see how these medications work with comorbid conditions, what side effects may emerge, and such, but the huge wave of medications coming through gives migraine patients across the globe new, innovative options that can change their life.
All information is intended to be educational, but is not intended to replace information from your doctor. I have done my best to convey the information in a way that is clear and to the point, but as I am interpreting it, some information may not be accurate and I would recommend looking at the clinical trials for the most factual representations.
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