The old rule was blunt. Before a migraine patient could get a drug built around CGRP, the previous American Headache Society consensus statements said they should first try at least 2 classes of older first-line medicines, each for at least 8 weeks. Beta blockers. Tricyclic antidepressants. A long shelf of established options, none of them designed around the CGRP pathway.
A new position statement from the society drops that requirement. For the first time, the AHS is calling for CGRP-targeting therapies to be used as a first-line approach to preventing migraine, NeurologyLive reported. Medical Independent, summarising the paper, said they should be considered alongside the earlier first-line treatments, with no need to fail other classes first.
What is on the list
CGRP, short for calcitonin gene-related peptide, is the molecule these drugs target. The class includes monoclonal antibodies (erenumab, fremenezumab, galcanezumab and eptinezumab) and small-molecule receptor blockers called gepants, such as rimegepant and atogepant. The statement’s treatment lists put the antibodies and the gepants next to beta blockers, tricyclic antidepressants and other established options for both episodic and chronic migraine. Nearly all CGRP-targeting therapies are FDA-approved for preventing both forms. Rimegepant, per NeurologyLive, is the exception, approved only for episodic migraine.
The society’s reasoning was evidence. Its taskforce, set up after discussions across 2022 and 2023, reviewed randomised placebo-controlled trials, post hoc analyses, open-label extensions and observational studies. The cumulative evidence for efficacy, safety and tolerability of these agents is significantly greater than for any established migraine preventive, the paper argued. Andrew Charles, president of the AHS and a professor at UCLA, called the surge in clinical trial and real-world data “astonishing.” “The evidence for their efficacy and especially their tolerability is just so overwhelming and our clinical experience backs that up,” he said. He added that the drugs work even in patients who have tried a host of other preventives and stopped them because of poor results or side effects.
The cost argument
Money is the sticking point, and the authors said so. The statement did not try to justify the price of CGRP therapies. It argued instead that decision-makers should weigh the substantial costs to the individual and to society if effective treatment is delayed. In some cases these drugs have reduced use of acute medication, which could mean savings, NeurologyLive noted, whereas similar evidence does not exist for the older preventives.
“It is clear that if cost were not a primary consideration, there would be no controversy regarding the legitimate place for CGRP-targeting therapies as a first-line option for migraine prevention,” Charles and his co-authors wrote.
Real-world studies have flagged constipation, hypertension and Raynaud’s phenomenon as concerns. These are mostly uncommon, the paper said, and do not usually require stopping treatment. Charles said moving the drugs to the front of the line should lower the barriers patients face and “bring hope to countless people who experience this invisible, yet debilitating disease.”
Sources
- American Headache Society Calls for CGRP Medications to be Considered as First-Line Migraine Preventive Treatments | NeurologyLive – Clinical Neurology News and Neurology Expert Insights
- CGRP-targeting therapies as first-line option for migraine prevention – Medical Independent
