American Headache Society Includes CGRP Inhibitors in Updated Consensus Statement

Providing healthcare professionals with up-to-date guidance for the use of novel treatments for migraine, the American Headache Society (AHS) has published a consensus statement outlining indications for initiating, continuing, combining, and switching treatments.

The consensus statement takes into account both preventive and acute treatments for migraine, including calcitonin gene-related peptide (CGRP) inhibitors, which first entered the market last year with the approval of erenumab (Aimovig), followed by fremanezumab (Ajovy), and galcanezumab (Emgality).

Input on the updated guidance came from a range of stakeholders, including health insurers, employers, pharmacy benefit service companies, pharmaceutical and biotechnology companies, and patient advocates.

Preventive treatment

Unchanged from previous guidance, AHS recommends preventive treatment when attacks significantly interfere with patients’ daily routines despite acute treatment; a patient has 4 or more attacks per month; or a patient has contraindication to, failure, or overuse of acute treatment.

"Prevention should also be considered in the management of certain uncommon migraine subtypes, including hemiplegic migraine, migraine with brainstem aura, migraine with prolonged aura, and those who have previously experienced a migrainous infarction, even if there is low attack frequency,” states the guidance.

In addition to the 3 FDA-approved CGRP inhibitors, onabotulinumtoxin A, commonly known as Botox, is approved as an injectable preventive treatment. In contrast to oral therapies, there is no need for gradual dose escalation for injectable therapies. This, in combination with rapid onset of benefits, is an advantage of injectable therapies compared with oral therapies, according to the statement.

While a signification reduction, often 50%, is a useful benchmark for measuring response, the statement notes that persistence and severity of pain and associated symptoms, level of disability, and functional capacity, are important markers.

For CGRP inhibitors, a significant proportion of patients achieve a response within the first month, but some patients achieve a response in the 4 weeks after the first dose, and a smaller proportion respond in 4 to 8 weeks after a third consecutive dose. “Therefore, it is recommended that the benefits of anti-CGRP monoclonal antibodies be assessed after 3 months of treatment for those administered monthly and 6 months after the start of quarterly treatments,” according to the statement.

Acute treatment

According to the consensus statement, all patients with migraine should be offered acute treatment. For mild to moderate attacks, they recommend using nonsteroidal anti-inflammatory drugs (NSAIDs), nonopioid analgesics, acetaminophen, or caffeinated analgesic combinations, and for moderate or severe attacks. For moderate to severe attacks that don’t respond to other treatments, they recommend migraine-specific agents, including triptans and dihydroergotamine.

In patients who experience nausea or vomiting during an attack, AHS recommends using a nonoral therapy, including sumatriptan 3, 4, or 6 mg.

“When first-line acute treatment does not bring relief, patients may require rescue mediation,” states the guidance. “Depending on the initial treatment, options for outpatient rescue include subcutaneous sumatriptan, dihydroergotamine (DHE) injection or intranasal spray, or corticosteroids; inpatient options may include parenteral formulations of triptans, DHE, antiemetics, NSAIDs, anticonvulsants, corticosteroids, and magnesium sulfate.”

They also note that patients who need to use acute treatment on a regular basis should limit treatment to an average of 2 headache days per week and patients exceeding this limit should be offered preventive treatment to avoid medication overuse.

Reference:

American Headache Society. The American Headache Soceity position statement on integrating new migraine treatments into clinical practice [published online December 10, 2018]. Headache. doi: 10.1111/head.13456.