1. Home>
2. Specialties>
3. Emergency Medicine>
4. Summary and Comment

New Class of Drugs for Acute Migraine

Telcagepant, a calcitonin gene-related peptide antagonist, is as effective as zolmitriptan, with fewer adverse effects.

Migraine headache is commonly treated with triptans (serotonin-receptor agonists), but, because these agents are associated with side effects (such as chest discomfort, dizziness, and throat tightness), they are poorly tolerated by some patients and contraindicated in those with cardiovascular disease. Telcagepant is a new calcitonin gene-related peptide antagonist that lacks the vasoconstrictor effects of triptans. In a randomized, controlled, double-blind, parallel-treatment trial funded by the maker of telcagepant, 1380 adult patients (mean age, 42; 85% female) with acute migraine received one of four oral treatments: telcagepant (160 mg or 300 mg), zolmitriptan (5 mg), or placebo. The study was conducted at 81 outpatient primary care and headache centers in Europe and the U.S.

Patients were excluded if they had cardiovascular disease or uncontrolled hypertension or had used selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, or propranolol within 1 month before the screening visit. Patients recorded headache pain severity (none, mild, moderate, or severe) and presence or absence of phonophobia, photophobia, and nausea at baseline; every 30 minutes for 3 hours; and at 4, 6, 8, and 24 hours.

Telcagepant 300 mg and zolmitriptan 5 mg were similarly effective, and both were superior to telcagepant 150 mg and placebo for pain relief; pain freedom; and absence of phonophobia, photophobia, and nausea. No deaths and only one serious adverse event (in a placebo recipient) were reported. Adverse events were significantly more common in the zolmitriptan group than in the other three groups.

Comment: An editorialist suggests that the proof of efficacy of telcagepant — the first of a new class of drugs — "marks a new era in migraine therapy." If approved by the FDA (the manufacturer plans to file a new drug application in 2009) and other regulatory agencies, telcagepant and its future congeners show promise as effective alternatives to triptans. This new drug might be another important step toward the goal of minimizing or eliminating emergency department visits by patients with chronic migraine syndromes.

— Kristi L. Koenig, MD, FACEP

Published in Journal Watch Emergency Medicine January 16, 2009

Citation(s):

Ho TW et al. Efficacy and tolerability of MK-0974 (telcagepant), a new oral antagonist of calcitonin gene-related peptide receptor, compared with zolmitriptan for acute migraine: A randomised, placebo-controlled, parallel-treatment trial. Lancet 2008 Dec 20; 372:2115.

• Medline abstract (Free)

Edvinsson L. CGRP-receptor antagonism in migraine treatment. Lancet 2008 Dec 20; 372:2089.

• Medline abstract (Free)