The pivotal role
of calcitonin gene-related peptide (CGRP) in migraine
pathophysiology was identified over 30 years ago, but the successful
clinical development of targeted therapies has only recently been
realized. This Perspective traces the decades long evolution of medicinal
chemistry required to advance small molecule CGRP receptor antagonists,
also called gepants, including the current clinical agents rimegepant,
vazegepant, ubrogepant, and atogepant. Providing clinically effective
blockade of CGRP signaling required surmounting multiple challenging
hurdles, including defeating a sizable ligand with subnanomolar affinity
for its receptor, designing antagonists with an extended confirmation
and multiple pharmacophores while retaining solubility and oral bioavailability,
and achieving circulating free plasma levels that provided near maximal
CGRP receptor coverage. The clinical efficacy of oral and intranasal
gepants and the injectable CGRP monoclonal antibodies (mAbs) are described,
as are recent synthetic developments that have benefited from new
structural biology data. The first oral gepant was recently approved
and heralds a new era in the treatment of migraine.