Short-term prevention of perimenstrual migraine with rimegepant

Menstrually-related migraine (MRM) affects approximately 31–52% of women with migraine and are characterized by increased frequency, severity, and reduced response to conventional therapy during the perimenstrual window. Traditional short-term prevention with non-steroidal anti-inflammatory drugs (NSAIDs) or triptans often fails due to intolerance or contraindications. Rimegepant, a calcitonin gene-related peptide (CGRP) receptor antagonist with indication for both acute and preventive therapy, may offer a novel short-term prophylactic option for perimenstrual migraine. This hypothesis-generating case series includes five women, aged 22–42 years, with episodic migraine and regular menstrual cycles, who received rimegepant 75 mg orally disintegrating tablet every other day, initiated two days prior menstruation and continued until two days post-menstruation. Patients recorded daily headache diaries, and key outcomes included reduction of perimenstrual migraine days, overall migraine frequency, tolerability, and adverse events. Follow-up was conducted after 3–4 cycles. Rimegepant prevented perimenstrual attacks in 17/20 cycles (85%) with no treatment-related adverse events in this small cohort. However, sustained monthly migraine day reduction occurred in only one patient (20%). Three patients (60%) experienced delayed migraine onset 3–7 days post-menstruation, suggesting “temporal displacement” rather than complete prevention. All patients reported high satisfaction with perimenstrual symptom control. Short-term rimegepant was well tolerated and prevented anticipated perimenstrual migraine attacks in most cases. The observed temporal displacement of migraine supports complex hormonal and CGRP-independent mechanisms in menstrual migraine. Randomized controlled trials are warranted to optimize treatment protocols and confirm these preliminary findings.