The American Headache Society, AHS, recommended in March 24, 2024, that the six CGRP drugs be considered as first line preventive treatment for migraine.

This is an article by Britt Talley Daniel MD, retired member of the American Academy of Neurology, Migraine textbook author, Podcaster, YouTube video producer, and Blogger.

 About Migraine

Migraine is a common, often lifelong, neurologic problem occurring in 26% of women and 6% of men. Migraine symptoms are severe, often one-sided headache, sensitivity to light, sound and odors, nausea and vomiting, and the need to be down.

The duration of a migraine may be 4 to 72 hours and the patient may be incapacitated during that time. The frequency is often 1 or 2 attacks per month and the headaches start in the late teens and taper off by age sixty or seventy.

 The Migraine process

In the migraine process the first step is trigeminal nerve activation.  Then in 20-40 minutes the ganglion of the trigeminal nerve and the artery start to release the neuroinflammatory chemicals:  CGRP, Neurokinin A, and Substance P.

These neurochemicals inflame the nerve, the artery, and the human pain center (the thalamus) and start arterial vasodilataion.

The CGRP antibodies block the release of CGRP, one of the central neurochemicals involved.

AHS statement

“The AHS calls for CGRP-targeting therapies to be considered as a first-line approach for migraine prevention, without a requirement for prior failure of other, older classes of migraine preventive treatment.”

Goal of preventive treatment

The goal of CGRP migraine preventive treatment is to reduce the frequency, intensity, duration, and disability associated with migraine attacks. AHS states that preventive therapy is indicated for approximately 40% of people with migraine.

The CGRP drugs

These are the monoclonal antibodies, Ajovy (fremanezumab), Emgality (galcanezumab), Aimovig (erenumab), and Vyepti (eptinezumab) and the small-molecule CGRP receptor antagonists Nurtec OTC (rimegepant) and Qulipta (atogepant).

AHS review results

The AHS “found the evidence supporting the efficacy, tolerability, and safety of CGRP-targeting therapies…for migraine prevention to be substantial in its volume, scope, and quality.”

AHS president Andrew Charles, MD, FAHS statement

"Moving CGRP-targeting therapies to the first line of treatment could have a transformational impact on the prevention of migraine attacks and their associated burdens. Elevating CGRP-targeting therapies to the first line should reduce barriers for patients to receive these effective treatments and bring hope to countless people who experience this invisible, yet debilitating disease."

 

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Britt Talley Daniel MD