Atogepant can be used as an option for the acute treatment of migraine with or without aura in adults, only if, for previous migraines:
at least 2 triptans were tried and they did not work well enough, or
triptans were contraindicated or not tolerated, and nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol were tried but did not work well enough.
Use the least expensive option of the suitable treatments (including atogepant and rimegepant), having discussed the advantages and disadvantages of the available treatments with the person with the condition. Take account of administration costs, dosages, price per dose and commercial arrangements.
This recommendation is not intended to affect treatment with atogepant that was started in the NHS before this guidance was published. People having treatment outside this recommendation may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS healthcare professional consider it appropriate to stop.
Atogepant must be funded in the NHS in England for the condition and population in the recommendations, if it is considered the most suitable treatment option. Atogepant must be funded in England within 30 days of final publication of this guidance.
There is enough evidence to show that atogepant provides benefits and value for money, so it can be used routinely across the NHS in this population.
NICE has produced tools and resources to support the implementation of this guidance.
Rimegepant is the usual acute treatment for migraine after at least 2 triptans have not worked well enough, or if people cannot have triptans, and NSAIDs and paracetamol do not work well enough.
Clinical trial evidence shows that atogepant is more effective than placebo. It has not been directly compared in a clinical trial with rimegepant. Evidence from an indirect comparison suggests that the levels of pain reduction at 2 hours are similar with atogepant and rimegepant. But these results are uncertain. This means that it is unclear from these results alone whether atogepant works the same as, or better or less well than, rimegepant. But, because the way the medicines work and are administered are similar, it is likely that their clinical effectiveness is similar. Clinical expert feedback supports this and states that they would be used at the same place in the treatment pathway.
A cost comparison suggests that the costs for atogepant are similar to or lower than those for rimegepant. So, atogepant can be used.
For all evidence, see the committee papers. For more information on NICE's evaluation of rimegepant, see the committee discussion section in NICE's technology appraisal guidance on rimegepant for treating migraine.