At the American Academy of Neurology (AAN) 2025 annual meeting, held in San Diego, California from 5 April to 9 April 2025, acute treatments for migraine were a key topic, with several posters and presentations focusing on real-world use and comparative efficacy of different treatment options. Acute treatments are used to provide headache relief during a migraine episode, and the current treatment landscape is highly competitive.
Oral triptans are considered the industry gold standard acute treatments and there are seven approved, all with comparable efficacy. Triptans are widely available, and there is a high level of genericisation in this drug class. However, triptans exhibit vasoconstriction of the cerebral, coronary and peripheral arteries and hence are contraindicated in patients who suffer from or are at risk of cardiovascular problems. Eli Lilly’s Reyvow (lasmiditan) and the newer gepant class provide alternative acute treatment options. Currently, AbbVie’s Ubrelvy (ubrogepant) and Pfizer’s Zavzpret (zavegepant) and Nurtec (rimegepant) are available for acute treatment in the US. To intensify the competition, novel drug combinations with triptans such as Axsome Therapeutics’ Symbravo (meloxicam and rizatriptan) are now emerging.
During AAN 2025, several posters comparing real-world use of Nurtec with triptans were presented. The first poster presented results from a real-world survey in patients receiving either Nurtec monotherapy or triptan monotherapy. In patients on Nurtec monotherapy, physician-reported consistency, defined as achieving pain freedom within two hours after treatment more than 50% of the time, was 73% compared with 57% for triptan monotherapy patients. Both physician and patient-reported satisfaction with their current acute treatment was higher for Nurtec monotherapy compared with triptan monotherapy. In a second poster, patient-reported outcomes were presented. This data also showed higher patient satisfaction among Nurtec users compared with triptan users, while further showing that patients using Nurtec had fewer hospitalisations and ER visits compared with triptan users.
The final poster focused on persistence – the continued use of a drug as required, in patients taking Nurtec or oral triptans (rizatriptan or sumatriptan). The results showed that three-quarters (75.3%) of patients taking Nurtec were persistent compared with just over half (53.5%) of those taking a triptan.
Although the triptans are expected to remain as first-line therapies for acute migraine treatment due to their wide generic availability and high physician familiarity, real-world data for other acute treatments, such as that presented for Nurtec, is important for establishing a drug’s position as a second-line therapy in this competitive space. Key opinion leaders (KOLs) previously interviewed by GlobalData had noted that the gepants had similar efficacy to the triptans and as such, favourable patient opinions of gepants could increase their prescription if it means that patients are more likely to persist with taking the drug, therefore gaining maximum treatment benefit, enabling more effective disease management.
Adding to the competition in the acute migraine space, Axsome Therapeutics’ Symbravo was approved by the FDA on 20 January 2025 for the acute treatment of migraine with or without aura in adults. On 8 April at AAN 2025, Axsome Therapeutics presented a network meta-analysis indirectly comparing the efficacy of Symbravo with the three gepants for the treatment of acute migraine in a poster session. The results of the analysis showed that Symbravo had the greatest probability of being the most effective treatment compared with the gepants at each endpoint that was assessed, including pain relief, pain freedom, ability to perform normal activity, absence of most bothersome symptoms and rescue medication use.
Symbravo was significantly more effective than the gepants in achieving pain freedom two hours after administration, as well as sustained pain freedom from two to 24 hours after administration. Although not a direct comparison in a clinical trial, Axsome will need to leverage analysis such as this to position Symbravo as an effective alternative acute treatment option for patients who have not responded to previous triptan treatments in an increasingly competitive market.
Axsome has also run a clinical trial, EMERGE: NCT05550207, that demonstrated that Symbravo was able to significantly improve migraine treatment response in patients who had previously had an inadequate response to either rimegepant or ubrogepant, further demonstrating the benefit of Symbravo and giving it a potentially unique market position, albeit later in the treatment algorithm. Despite the positive data, KOL opinion of Symbravo was mixed, with several KOLs highlighting concerns over cost, especially given that fixed-dose combination drugs tend to be expensive, yet both meloxicam and rizatriptan are available separately as generics. The high cost of Symbravo shows that, commercially, Axsome is looking to position it more in line with the gepants and further from the cheap generic triptans, increasing the likelihood of Symbravo being used later in the acute migraine treatment algorithm.
