CGRP Receptor Antagonist (Gepant — Migraine Prevention)

Atogepant

Brand names: Aquipta

Adult dose

Dose: 60 mg once daily

Route: Oral

Frequency: Once daily

Clinical pearls

Oral CGRP receptor antagonist for preventive treatment of episodic and chronic migraine in adults
ADVANCE and PROGRESS trials demonstrated efficacy in reducing monthly migraine days
NICE TA913 (2024): atogepant recommended for preventive treatment of episodic migraine (≥4 migraine days/month) when ≥3 previous preventive treatments have failed or are contraindicated
Mechanism: blocks CGRP receptor (unlike anti-CGRP monoclonal antibodies which bind CGRP ligand or receptor)
No hepatotoxicity concern at therapeutic doses (unlike older CGRP antagonists — telcagepant — which were discontinued)
Advantages over injectables (erenumab, fremanezumab): oral, no injection site reactions, no anti-drug antibodies

Contraindications

Severe hepatic impairment
Concomitant potent CYP3A4 inhibitors (dose reduction to 10 mg once daily required — check SmPC)
Concomitant OATP1B1/1B3 inhibitors (dose reduction required)

Side effects

Nausea
Constipation
Fatigue
Decreased appetite
Elevated LFTs (uncommon)

Interactions

Strong CYP3A4 inhibitors (itraconazole, clarithromycin) — increase atogepant levels; reduce atogepant to 10 mg
Strong CYP3A4 inducers (rifampicin, carbamazepine) — reduce atogepant levels; avoid combination
OATP1B1/1B3 inhibitors (ciclosporin) — increase atogepant; reduce dose

Monitoring

Migraine frequency and severity (diary — monthly migraine days)
LFTs at baseline and periodically
Response at 3 months — continue only if effective

Reference: BNF; NICE TA913 (Atogepant for preventing migraine, 2024); ADVANCE trial (NEJM 2021); BASH UK Migraine Guidelines (2023); https://bnf.nice.org.uk/drugs/atogepant/. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways