CGRP-targeting Monoclonal Antibodies Safe, Effective in Treatment of Migraine

Calcitonin gene-related peptide (CGRP) targeting monoclonal antibodies can be a successful, safe option for migraine treatment, according to a recent presentation at Neurology Week.

Several recent trials provide clinical evidence in support of CGRP-targeting monoclonal antibodies for migraine treatment, which were found to work in patients with a lack of previous response to other migraine treatment options, said Larry Charleston, IV, MD, MSc, FAHS, Director, Headache Medicine and Facial Pain, Michigan State University, East Lansing, Michigan.

“Monoclonal antibodies are superior to traditional treatment when efficacy and AEs [adverse effects] are evaluated,” Dr Charleston said.

The four monoclonal antibodies, large molecules that do not pass into the brain, include erenumab, fremanezumab, galcanezumab, and eptinezumbad. All are antibodies against the CGRP ligand, peptide, or receptor.

Erenumab and galcanezumab are self-injected monthly, fremanezumab is self-injected monthly or every 3 months, and eptinezumbad is received through IV-infusion every 3 months.

When compared to older migraine treatments in placebo-subtracted analyses, monoclonal antibodies caused less adverse events, and performed better in three separate benefit/risk assessments; number needed to treat (NNT), number needed to harm (NNH), and number needed to treat versus harm (LLH).

Patients on monoclonal antibodies saw a reduction in monthly migraine days, and fast onset.

An unprecedented 75% and 100% responder rate was recorded for galcanezumab.

“These placebo-subtracted analyses suggest the superiority of the MABs over traditional treatments and also suggest a treatment paradigm shift,” Dr Charleston highlighted in the presentation.

Dr Charleston noted monoclonal antibodies should be available to be prescribed to patients with lower-frequency episodic migraine, high-frequency episodic migraine, and chronic migraine who meet the criteria.

Criteria for patients with lower-frequency episodic migraine includes a lack of success with 2 level A or B migraine preventative medications and documented moderate disability by migraines; criteria for patients with high-frequency episodic migraine include lack of success with 2 level A or B migraine preventative medications; and criteria for patients with chronic migraine include lack of success with 2 level A or B migraine preventative medications additionally including onabotulinumtoxinA.

Following use of monoclonal antibodies, in a clinical futility exercise, only 17% of patients continued traditional prevention across the year.

“So far, short answer, yes, they are effective, safe, and well tolerated,” Charleston said. “Stratified care, in which we match patient need to treatment choice, is likely to result in a greater likelihood of optimal outcome for patients, rather than stepping through traditional treatments.”—Erin McGuinness

Charleston, L. Time To Focus On What Matters Most: Utilizing CGRP-targeting Monoclonal Antibodies For Prevention. Presented at Neurology Week 2021; July 14-18. Virtual.