Migraine prevention should include CGRP-targeting therapies as first-line agents

The American Headache Society (AHS) has updated its position statement regarding therapies targeting calcitonin gene-related peptide (CGRP) for the prevention of migraine. The AHS notes that all migraine preventive therapies previously considered to be first-line treatments such as beta-blockers (e.g., metoprolol, propranolol, timolol), antiseizure medications (e.g., topiramate, valproate/divalproex), antidepressants (e.g., amitriptyline, nortriptyline, venlafaxine, duloxetine) and onabotulinumtoxinA were developed for other indications and adopted later for migraine. Adherence to these therapies is often poor due to lack of efficacy and poor tolerability. According to the AHS, CGRP-targeting therapies have had a significant impact on the management of migraine but they are still not widely considered to be first-line agents. CGRP-targeting migraine preventive therapies include monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) and the gepants (rimegepant and atogepant). The AHS found substantial evidence for the efficacy, tolerability and safety of these agents, which vastly exceeds that for any other preventive treatment approach. The evidence is consistent across different individual CGRP-targeting treatments and has been corroborated by extensive “real-world” clinical experience with these agents. Overall, the efficacy and tolerability of CGRP-targeting therapies is comparable to or greater than that of previous first-line therapies. In addition, serious adverse events associated with CGRP-targeting therapies are rare.The AHS concludes that CGRP-targeting therapies should be considered as first-line options for migraine prevention along with previous first-line treatments. Prior failure of other classes of migraine preventive treatments should not be required before using CGRP-targeting therapies for migraine prevention. Based on current Canadian product monographs, erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), eptinezumab (Vyepti) and atogepant (Qulipta) are approved for migraine prevention in Canada. Rimegepant (Nurtec ODT) and ubrogepant (Ubrelvy) are currently indicated only for acute treatment of migraine in Canada. Reference:1. Charles AC, Digre KB, Goadsby PJ, et al; The American Headache Society. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: An American Headache Society position statement update. Headache 2024;64:333-41. (accessed June 27, 2024).

Migraine prevention should include CGRP-targeting therapies as first-line agents

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