Migraine Expert Renews Call for Prompt, Effective Management
OTTAWA — Therapies that target calcitonin gene-related peptide (CGRP) should be used up front in the treatment and prevention of migraine because of their efficacy, safety, and potential to modify the disease course, an expert said.
Speaking at the annual meeting of the Canadian Neurological Sciences Federation (CNSF) Congress 2025, David Dodick, MD, emeritus professor of neurology at Mayo Clinic in Phoenix, reiterated the appeal that was first published in an American Headache Society position statement: That migraine therapies that target CGRP become first-line treatments for migraine.
A Bold Call
Some of the available monoclonal antibodies to treat migraine include erenumab, fremanezumab, galcanezumab, and eptinezumab. The class of 'gepants' includes rimegepant and atogepant. All these treatments target CGRP.
'This was a type of expert consensus opinion,' Dodick told Medscape Medical News , referring to the 'rather bold' position statement. 'The real-world evidence supports what we saw in clinical trials, and we now know the safety profile of these [therapies] because we've had them for almost 8 years of use in clinical practice. They are not first-line [therapies] simply because of cost.'
The largest prospective study on the use of anti-CGRP monoclonal antibodies demonstrated robust responses to these therapies.
Because CGRP-targeting therapies are well tolerated, discontinuation due to adverse events is generally not a concern, and increased efficacy may be realized if patients stay the course with CGRP-targeting therapies, said Dodick.
'You can imagine that if people are able to tolerate them and stay on these drugs longer, then efficacy is cumulative over time. Adherence and compliance increase the response rate over time,' said Dodick.
Early Treatment Vital
'It really does matter how early you get to the patient and treat them effectively, both from the standpoint of treating an individual episode of migraine and from the prevention standpoint: That is, treating the disease earlier,' said Dodick. 'The more frequent that migraines are, and the more you allow them to be frequent, the more likely they are to progress to a daily migraine, and the more difficult they are to manage.'
In the US and Canada, patients with migraine must first fail other treatments before they are prescribed newer agents like CGRP monoclonal antibodies or gepants, and this requirement creates the potential for a lapse in care, noted Dodick. 'Patients can become discouraged and lost to follow-up if they fail one medicine and then two medicines,' which he said supports the case for first-line access to CGRP-targeting migraine therapies.
High-Impact Agents
The efficacy of migraine treatments that target CGRP is convincing, said Michael Hill, MD, professor of clinical neuroscience at the University of Calgary's Cumming School of Medicine, Calgary. 'For some patients, they can get back to living a relatively normal life,' said Hill, who also is CNSF president. 'It can be a remarkable evolution. They go from being nonfunctioning and not working to being fully functional again because their migraine is not chronic, or their recurrent migraines are not so disabling.'
Seeing patients who are unable to access these therapies is disheartening, Hill told Medscape Medical News. 'It is hard to see them denied this therapy.'
The preventive potential that these therapies could offer would certainly be welcome, Hill added. 'The idea that some of these people who start with simple migraine and progress to a chronic, refractory migraine state, and that these might actually be preventable with early treatment, is really exciting.' Episodic treatment of migraine has not altered the disease course. 'The focus on migraine therapy has been on acute treatment and not so much on this idea that you might prevent the evolving chronicity of the disease.'
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