Rimegepant shows real-world benefit in treatment-resistant migraine

Clinical takeaway: Consider preventive rimegepant even after prior anti-CGRP monoclonal antibody failure, although patients with fewer prior preventive treatment failures may respond best.

Patients with treatment-resistant migraine experienced clinically meaningful reductions in headache frequency with preventive rimegepant, according to a prospective multicenter real-world study. The findings suggest that patients may still benefit from rimegepant despite prior failure of anti-CGRP monoclonal antibodies, a common treatment sequence in US practice.

The study included 150 adults treated at nine tertiary headache centers in Spain. Participants had failed a median of six preventive therapies. More than half had previously received onabotulinumtoxinA, and nearly 40% had received an anti-CGRP monoclonal antibody. After three months of treatment, median monthly headache days decreased from 12 to 7.5 and monthly migraine days from 10 to 6. At least a 50% reduction in monthly headache days was achieved by 36% of patients, increasing to 48% among those with six months of follow-up.

Patients with medication overuse, chronic migraine, and greater prior treatment exposure were less likely to respond. However, many patients with prior anti-CGRP monoclonal antibody exposure still achieved clinically meaningful improvement despite their high treatment burden.

Rimegepant was generally well tolerated. The most common adverse events were nausea (13%) and constipation (8%), and only 7% of patients discontinued treatment within three months because of inadequate efficacy or adverse events.

Overall, the study supports earlier consideration of rimegepant before migraine becomes highly treatment resistant.

Source: Gago-Veiga AB, et al. (2026 July 6). Cephalalgia. Rimegepant for migraine prevention in clinical practice: A multicenter study including patients with prior anti-CGRP monoclonal antibody failure