To evaluate the co-prescription of calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) and gepants (small molecule CGRP receptor antagonists) at a tertiary headache center.

Given the similarities between CGRP mAbs and gepants, the impact on patients receiving both is unclear. Case series and retrospective studies have suggested a potential synergistic benefit; however, there is a concern for increased side effects due to greater inhibition of the CGRP pathway.

This is a retrospective cohort study using aggregated, de-identified, patient data of 1,548 patients with chronic migraine who received a prescription for a CGRP mAb(n=586), a gepant (n=621), or both(n=340) between May 2018 and June 2023 from the Stanford Headache Clinic. We compared characteristics of patients with chronic migraine who received co-prescriptions for both a gepant and a CGRP mAb to patients with chronic migraine who were prescribed only one of these medications.

Since their release, the prescription rate of gepants has had a steady increase (17.3% of patients by the second quarter of 2023) while the prescription rate of CGRP mAbs has remained stable (12.5% of the same cohort). When evaluating the co-prescription of both gepants and CGRP mAbs during this time, there has been no notable change over time, with a co-prescription rate of 1.8% by the second quarter of 2023.

The group concurrently receiving both a gepant and a CGRP mAb was similar to the overall clinic population for sex, zip code income distribution, and age (all p>0.05), but with a higher percentage identifying as non-Hispanic/Latino (90.3% vs. 76.4%, p<0.001).

The availability of both the CGRP mAbs and gepants was not associated with an increase in their co-prescription. Further prospective trials are needed to evaluate the safety and efficacy of this combination. Additionally, racial and ethnic disparities are critical to address in the co-prescription of more expensive medications.