Insufficient Evidence for Anti-CGRP Treatment Guideline for Migraine

The European Headache Federation (EHF) recently sought to create an expert- and evidence-based guideline for the treatment of migraine with monoclonal antibodies. However, in reviewing available research, the EHF found that there was not enough evidence to provide a guideline based on the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach.

The EHF evaluated 4 monoclonal antibodies: eptinezumab, fremanezumab, and galcanezumab, which target the calcitonin gene-related peptide (CGRP); and erenumab, which targets the CGRP receptor. Researchers included 28 previous studies in the analysis. During their review of the literature, the study authors assessed the quality of the evidence provided throughout the literature and consulted expert opinions when the GRADE approach was not applicable.

“We found low to high quality of evidence to recommend eptinezumab, erenumab, fremanezumab, and galcanezumab in patients with episodic migraine and medium to high quality of evidence to recommend erenumab, fremanezumab, and galcanezumab in patients with chronic migraine,” wrote the authors.

After completing a review of available data, the researchers determined that erenumab, fremanezumab, and galcanezumab are effective for prevention in patients with episodic migraine. These drugs were found to reduce the number of headache or migraine days, reduce the number of days using acute medications, and improve disability. For eptinezumab, benefits were “not entirely clear” and improvement was significant only in the reduction of medications used for acute attacks.

The study authors concluded that monoclonal antibodies “appear promising drugs for migraine prevention. Real-world data will be very important to support efficacy and safety of those drugs particularly in the long-term. Future biomarker research should identify patients more prone to respond to CGRP [monoclonal antibodies] and enable clinicians to personalize treatment decisions.” Although previous data appeared promising, the EHF were unable to provide recommendations using the GRADE approach thus far.

Reference

Sacco S, Bendtsen L, Ashina M, et al. European headache federation guideline on the use of monoclonal antibodies acting on the calcitonin gene related peptide or its receptor for migraine prevention [published online January 16, 2019]. J Headache Pain. doi: 10.1186/s10194-018-0955-y.