Migraines are a chronic and debilitating condition affecting millions of people worldwide, and the search for effective treatment has led to the development of new medications like gepants. These drugs, including atogepant, rimegepant, and ubrogepant, are part of a class known as CGRP (calcitonin gene-related peptide) inhibitors. They target specific proteins in the brain believed to play a role in migraine attacks. Marketed as a breakthrough in migraine prevention and treatment, gepants are now available through the NHS at a cost of around £500 per month per patient. But is this high cost justified? And, more importantly, are these drugs truly as effective and safe as they claim to be?
How Do Gepants Work?
Gepants, such as atogepant, rimegepant, and ubrogepant, work by blocking the CGRP receptor, which is believed to cause inflammation and pain during a migraine. Unlike older treatments such as triptans, which constrict blood vessels, gepants target specific migraine pathways without affecting the cardiovascular system. This makes them an option for people with heart conditions who cannot use triptans. Gepants are available in oral tablet form and are used either for acute migraine treatment or for prevention of chronic and episodic migraines.
While gepants are heralded as a new solution for migraine sufferers, it’s crucial to weigh their benefits against their side effects, costs, and overall effectiveness. In particular, patients should be aware of the potential downsides that come with using these medications.
What Are the Side Effects of Gepants?
While gepants are generally marketed as well-tolerated, they do come with a range of potential side effects. Some studies, such as one on episodic migraine sufferers, found no significant difference in side effects between those taking a CGRP inhibitor and those given a placebo (sugar pill). However, this does not mean that they are free from adverse effects.
Below are the commonly reported side effects of gepants:
- Nausea and Vomiting
- Prevalence: These are among the most commonly reported side effects. Many patients who take gepants report nausea, sometimes accompanied by vomiting.
- Impact: While nausea may be mild, in some cases it can be severe enough to interfere with daily life, particularly for patients already suffering from frequent migraines.
- Back Pain and Joint Stiffness
- Prevalence: Some patients experience muscle or back pain as a side effect of taking gepants. Joint stiffness has also been reported.
- Impact: This can be particularly troubling for those who already experience muscle tension or body pain as part of their migraine symptoms.
- Headache and Visual Problems
- Prevalence: Ironically, headaches are another reported side effect of gepants. Visual disturbances, including blurred vision, have also been noted by some users.
- Impact: For a drug intended to relieve headaches, this side effect is particularly concerning. The severity can vary, and visual problems can limit patients’ ability to perform tasks requiring focus, such as reading or working.
- Tingling or “Pins and Needles” Sensations
- Prevalence: Some patients report feeling tingling or paresthesia, commonly described as a “pins and needles” sensation in the extremities.
- Impact: While typically not painful, this can be distracting and uncomfortable, particularly for patients who are already struggling with sensory overload due to migraines.
- Dry Mouth
- Prevalence: Dry mouth is a commonly reported side effect, which can lead to discomfort and increased thirst.
- Impact: While mild, this symptom can be aggravating, especially for patients who are already managing multiple migraine triggers such as dehydration.
- Upper Respiratory Infections and Urinary Tract Infections (UTIs)
- Prevalence: Some patients report infections such as upper respiratory tract infections (e.g., colds, sinus infections) or urinary tract infections.
- Impact: These infections can be serious in some cases and require additional medical attention. They also pose a risk for people with compromised immune systems.
- Fatigue
- Prevalence: Fatigue is another commonly reported side effect of gepants, affecting patients’ energy levels and overall ability to carry out daily tasks.
- Impact: For individuals already battling the fatigue that comes with migraines, this can make life even more difficult.
- Liver Toxicity
- Prevalence: In rare cases, gepants have been linked to elevated liver enzymes, which can be an early sign of liver toxicity. This side effect requires monitoring, especially for patients on long-term treatment.
- Impact: Liver toxicity can be dangerous and may necessitate stopping the medication if enzyme levels become too high.
- Injection-Site Pain (For Injectable CGRP Inhibitors)
- Prevalence: For patients using injectable forms of CGRP inhibitors, pain at the injection site is a commonly reported side effect. Although atogepant and ubrogepant are oral medications, other CGRP inhibitors require injections or infusions.
- Impact: This can be an issue for patients who are sensitive to injections or are prone to bruising and discomfort after receiving the shot.
- Driving Restrictions and Machinery Use
- Prevalence: One of the more restrictive aspects of using gepants is the advice that patients avoid driving or operating heavy machinery while taking the medication.
- Impact: This limitation can severely impact a patient’s day-to-day life, especially those who rely on driving for work or caregiving responsibilities.
Side Effect | Description |
---|---|
Nausea and Vomiting | Common side effect; can range from mild to severe. |
Back Pain and Joint Stiffness | Some patients report muscle pain and joint discomfort. |
Headache and Visual Problems | Ironically, headaches and blurred vision can occur. |
Tingling or "Pins and Needles" | Sensations of tingling in the extremities. |
Dry Mouth | Commonly reported; can cause discomfort and increased thirst. |
Fatigue | Can lead to decreased energy and lethargy. |
Liver Toxicity | Rare, but possible; requires monitoring of liver enzyme levels. |
Upper Respiratory/UTIs | Some patients report infections such as colds or UTIs. |
Driving/Machinery Restrictions | Patients are advised not to drive or operate heavy machinery. |
Injection-Site Pain (for injections) | Pain or irritation at injection sites for CGRP injections. |
The Costs of Gepants
The high price tag associated with gepants is a significant consideration, particularly for health systems like the NHS. At approximately £500 per month per patient, the long-term cost of providing these medications can be substantial. With the cost of gepants far exceeding that of older migraine treatments like triptans and over-the-counter pain relievers, patients and healthcare providers must weigh the benefits carefully.
Furthermore, while some patients report life-changing relief from gepants, others find that the benefits are not always worth the financial cost, particularly when weighed against the potential side effects.
Should You Consider Natural Alternatives?
Given the potential side effects and high costs associated with gepants, it may be worth considering natural alternatives before committing to long-term treatment. Supplements like vitamin B2 (riboflavin), magnesium, and Coenzyme Q10 have been shown to reduce the frequency of migraines in some people and may serve as a safer, more cost-effective option for migraine management.
NICE has even listed vitamin B2, CoQ10, and magnesium as frontline treatments for preventing migraines, though they are often overlooked in favor of pharmaceutical solutions. These supplements are widely available, inexpensive, and come with far fewer side effects than gepants or other prescription medications.
Conclusion
While gepants like atogepant, rimegepant, and ubrogepant are a promising new class of migraine medications, they are not without drawbacks. Side effects such as nausea, headaches, and liver toxicity can make them difficult for some patients to tolerate, and the high cost—£500 per month to the NHS—raises questions about their overall value.
Before turning to gepants, patients should explore natural alternatives such as vitamin B2 (riboflavin), magnesium, and Coenzyme Q10. These supplements are not only affordable but also come with minimal side effects. For some patients, combining natural supplements with medication may provide the best results, but always consult with a healthcare provider to find the right approach.
References:
- National Institute for Health and Care Excellence (NICE)
- Oxford University research on the efficacy of older vs. newer migraine medications
- Migraine Trust