Rationale for Correct Answer
The correct answer is: Yes, select a gepant due to their shorter half-lives
A drug is considered to be eliminated from the body when 5 times its half-life have passed.1 Gepants have a half-life of 5 to 11 hours. Anti-CGRP monoclonal antibodies have a half-life of 27-31 days, meaning that at least 5 months must elapse between discontinuing a monoclonal antibody and attempting to conceive.2 About 45% of pregnancies are unplanned.3 For women of reproductive age, a gepant may be a safer option.1 The American College of Obstetricians and Gynecologists does not recommend the use of gepants or monoclonal antibodies during pregnancy.4
According to the American Headache Society Consensus Statement the goals of migraine prevention are to reduce attack frequency, severity, duration, and disability and improve responsiveness to avoid escalation of acute treatment. Preventative treatment should be considered when a person living with migraine has frequent attacks that significantly interfere with their daily routine despite acute treatment or acute treatment has failed in some way (overuse, adverse events, contraindications).
Both attack frequency and degree of disability should be considered before offering preventative treatment. For example, a patient with 6 or more monthly headache days would not require proof of disability to qualify for preventative treatment, whereas a person with 3 or more monthly headache days would.
References:
1. Al-Hassany I, et al. Lancet Neurol. 2022;21(3):284-94;
2. Kielbasa W, et al. Cephalalgia. 2019;39(10):1284-97;
3. Tepper D. Headache. 2020; 60(5):1037-39;
4. Headaches in Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 3. Obstet Gynecol. 2022;139(5):944-72;
5. Ailani J, et al. Headache. 2021;61(7):1021-39.