Higher Dosage of Erenumab Shows Improved Efficacy for Preventive Migraine Treatment

Patients with prior preventive treatment failures for migraine were shown to benefit more from a higher dose of erenumab (140 mg) versus a lower dose (70 mg), according to a study published last week in The Journal of Headache and Pain.

The first specific treatment for the prevention of episodic migraine (EM) or chronic migraine (CM) utilizes monoclonal antibodies which act on the calcitonin gene-related peptide (CGRP) or its receptor. The efficacy and safety of these drugs has made them suitable for most patients with migraines, but their high cost makes patient selection an important issue. Currently, the American Headache Society and the European Headache Federation recommend monoclonal antibodies acting on the CGRP or its receptor in patients who failed at least 2 of the available preventive treatments.

Erenumab, a fully human monoclonal antibody directed against the CGRP receptor, which was approved for the prevention of EM or CM at the monthly dose of 70 mg or 140 mg, is recommended in its lower dose to most patients with migraine, while the higher dose provides an additional benefit to some patients. Researchers sought to examine whether patients who had failed prior preventive treatments for migraine would benefit more from a higher dose of erenumab versus a lower dose.

The researchers searched papers indexed in PubMed and conference abstracts published in the last 2 years that assessed the safety and efficacy of erenumab in patients with prior migraine preventive treatment failures. Additional analyses were conducted on the results of 3 randomized controlled trials (NCT02066415, STRIVE, and LIBERTY) and their subgroup analyses and open-label extensions.

The researchers found in the double-blind phases of the trials and their open-label extensions that the 140 mg monthly dose of erenumab had a numerical advantage over the 70 mg monthly dose in patients with prior treatment failures for migraine, both in EM and CM. The numerical difference between the 2 doses grew with the increase in the number of prior preventive treatment failures, indicating a heightened benefit from the higher 140 mg dose.

The study authors noted that, while no data directly compared the efficacy of the 70 mg and 140 mg dose or randomized dose-escalation studies, raw numbers suggest a slight clinical advantage, found more in patients with EM and increased prior preventive treatment failures, for the 140 mg monthly erenumab dose. “This treatment strategy will be feasible without additional costs or patient discomfort, since erenumab will be commercially available also in a single 140-mg injection,” said the authors.

Data lacking in the analyses were assessments of whether the response to different erenumab doses of CM is different from that of EM, and whether the benefit of the 140 mg dose over the 70 mg dose in patients with multiple prior preventive treatment failures is sustained over time.

“Further open-label and real-world studies will address the long-term benefit of starting—or switching to–the treatment with high-dose erenumab,” said the authors.

Reference

Ornello R, Tiseo C, Frattale I, et al. The appropriate dosing of erenumab for migraine prevention after multiple preventive treatment failures. J Headache Pain. 2019;20(99). doi: 10.1186/s10194-019-1054-4.