The most useful thing to understand about the newer migraine drugs is not which brand is best — it is that they answer two different questions. Some are acute treatments, taken to stop an attack that has started. Others are preventive, taken regularly to make attacks less frequent. One drug does both. Comparing an acute drug with a preventive one on "which works better" is a category error, and it is the most common source of confusion in this area.
This is an orientation for a conversation with your prescriber, not a recommendation. Which of these is appropriate depends on your attack frequency, your medical history, what you have already tried, and what your insurance or health system will fund.
The Line That Actually Matters
| Treatment | Type | Route | Taken |
|---|---|---|---|
| Ubrelvy (ubrogepant) | Acute | Tablet | When an attack starts |
| Nurtec (rimegepant) | Both | Dissolving tablet | For an attack, or every other day to prevent |
| Qulipta (atogepant) | Preventive | Tablet | Daily |
| CGRP injections (erenumab, fremanezumab, galcanezumab, eptinezumab) | Preventive | Injection / infusion | Monthly or quarterly |
| Botox (onabotulinumtoxinA) | Preventive | Injections | Every 12 weeks |
Nurtec being in both columns is genuinely useful for some people and genuinely confusing for everyone else. It is the reason "Qulipta vs Nurtec" is not a like-for-like comparison unless you specify which use you mean.
What They Have in Common
Ubrelvy, Nurtec and Qulipta are all gepants — small-molecule drugs that block the CGRP receptor. The injectable preventives are monoclonal antibodies targeting CGRP or its receptor. Both families act on the same pathway; they differ in size, route and how long they last.
Botox is the outlier: a different mechanism entirely, and licensed specifically for chronic migraine — generally meaning 15 or more headache days a month — rather than episodic migraine.
What the Evidence Base Looks Like
The gepants and the CGRP antibodies arrived with substantial randomised trials.
Two points of context that matter more than any single trial:
- Cross-trial comparison is unreliable. These drugs were largely tested against placebo, not against each other, in different populations with different entry criteria. "Drug A reduced attacks by X and drug B by Y" across separate trials does not establish that A beats B.
- The guidance has moved. The American Headache Society's 2024 position statement update treats CGRP-targeting therapies as a first-line option for migraine prevention, rather than something to reach for only after older preventives have failed. If you were told years ago that you had to fail two or three older drugs first, that advice may be out of date — worth asking about.
The broader 2021 AHS consensus statement covers how these fit alongside behavioural approaches and neuromodulation.
The Questions That Usually Decide It
In practice the choice tends to turn on these rather than on efficacy rankings:
- How often do you get attacks? Frequent attacks push toward prevention; infrequent ones toward a good acute drug. Our guide to acute versus preventive treatment covers where the line usually falls.
- Do you have chronic migraine? Botox is licensed for chronic, not episodic.
- Can you swallow and keep down a tablet? If nausea is prominent, oral acute drugs may be absorbed poorly — see migraine nausea. Dissolving or injectable options exist for this reason.
- Are you already using acute medication frequently? Medication-overuse headache changes the plan entirely. Check your medication-use days.
- What will actually be funded? Often the real constraint, and worth asking about early.
- Are you pregnant, planning pregnancy, or breastfeeding? This materially changes the options and needs specialist input.
Important Safety Note
These medications have different contraindications, interactions and side-effect profiles, and none of them is suitable for everyone. Do not start, stop, switch or combine migraine medications without your prescriber — including stopping a preventive because it "isn't working yet", since preventives typically need 8-12 weeks at an adequate dose before response can be judged. Tell your prescriber about all other medications, and about pregnancy or plans to conceive. Seek urgent medical advice for a severe allergic reaction, new or worsening high blood pressure, severe constipation, or any new or unusual symptom after starting a new drug.
This article is educational and is not a substitute for individual medical advice.
What to Track — and Why It Decides Your Next Appointment
The measure differs by drug type, and using the wrong one is how effective treatments get abandoned.
For an acute drug (Ubrelvy, Nurtec as needed), track per attack:
| Field | Why |
|---|---|
| Time symptoms started, time you dosed | Late dosing mimics drug failure |
| Pain-free at 2 hours? | The standard endpoint |
| Recurrence within 24 hours? | A different problem from non-response |
| Side effects | Separates ineffective from intolerable |
For a preventive (Qulipta, Nurtec every other day, CGRP injections, Botox), track per month:
| Field | Why |
|---|---|
| Monthly headache days | The primary outcome in every preventive trial |
| Attack severity and duration | Preventives often reduce these before they reduce count |
| Acute medication days | A key secondary outcome, and a medication-overuse check |
| Weeks since starting | Judging before 8-12 weeks is the commonest mistake |
That last row matters. A preventive stopped at week four because "nothing changed" was very likely stopped before it had a fair chance.
The medication effectiveness tracker covers the acute measures, and the preventive treatment progress calculator tracks monthly headache days against your start date. Recording both continuously in Migraine Trail produces a report with the before-and-after comparison your prescriber needs to decide whether to continue, switch, or escalate — which is very hard to reconstruct from memory across a 12-week trial.
If an attack breaks through during that trial, see how to judge whether migraine prevention is still working. If acute-treatment days are rising, review rebound headache and medication-overuse patterns.
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