Rationale for Correct Answer

The correct answer is: Yes, rimegepant or zavegepant, given her triptan intolerance and severe vomiting

Triptans selectively target 5-hydroxytryptamine (5-HT) receptors, primarily 5-HT1B and 5-HT1D receptors. Triptans relieve migraine pain by reducing neurogenic inflammation, lessening meningeal vessel vasoconstriction, and modulating second-order neurons. While triptans are generally well-tolerated, common adverse effects include paraesthesias, numbness, warmth, and pressure or tightness in the chest and neck. Triptans are contraindicated in patients with coronary artery disease (CAD), cerebrovascular disease, peripheral vascular disease, and uncontrolled hypertension. Prolonged or excessive triptan use can lead to medication overuse headaches. Triptans are cost effective and available as generic medications.1

Rimegepant and zavegepant are available in orally disintegrating tablets and nasal spray, respectively. These formulations can be helpful for people with vomiting and migraine and are alternatives for people with migraine and triptan intolerance.

Constipation, as an adverse reaction, was not significantly reported in rimegepant, zavagepant, or ubrogepant trials. However, in atogepant trials, constipation was observed in 6% of participants (pooled data) and led to discontinuation in 0.5% of cases.2 Erenumab, a monoclonal antibody that blocks CGRP at the receptor, has also been associated with severe cases of constipation.3

According to guidance from the American Headache Society, gepant use is appropriate for acute migraine treatment in adult patients with 1 of the following criteria4:

  • Contraindications to or inability to tolerate triptans
  • Inadequate response to 2 or more oral triptans, as determined by EITHER of the following:
    • Validated acute treatment patient-reported outcome questionnaire
    • Clinician attestation

1. LeClair JN, et al. An overview of generic triptans for migraine. US Pharm. Published online June 17, 2017. https://www.uspharmacist.com/article/an-overview-of-generic-triptans-for-migraine;
2. Qulipta. Package insert. AbbVie.; 2023;
3. Holzer P et al. Front Physiol. 2022;11;12:820006;
4. Ailani J, et al. Headache. 2021;61(7):1021-39.