Data Show Migraineurs Who Respond to Triptans More Likely to Respond to Erenumab

Compared with triptan nonresponders, patients with migraine who report a response to at least 1 triptan have a higher likelihood of responding to treatment with erenumab, according to real-world data published in The Journal of Headache and Pain.

While acute migraine-specific treatments, most notably triptans, have been available since the 1990s, erenumab—a monoclonal antibody—was approved by the FDA in 2018. It is administered monthly via self-injection of a 70- or 140-mg dose and blocks the calcitonin gene-related peptide (CGRP) receptor, which is believed to play a crucial role in migraine.

Similarly, “at the peripheral level, triptans constrict extracerebral blood vessels and reduce trigeminal sensory nerve activation, thus ultimately inhibiting vasoactive peptide release including substance P and CGRP,” authors wrote. Because triptans indirectly share their target with erenumab, researchers hypothesized that migraineurs who respond favorably to triptans might also respond to new preventive treatments.

To determine if previous response to triptans predicts the efficacy of erenumab, if the loss of efficacy of triptans over time predicts erenumab’s ineffectiveness, and if erenumab treatment improves the efficacy of triptans, researchers analyzed data of all patients treated with erenumab between January 2019 through March 2020 at several headache centers in Italy.

All participants were between ages 18 and 65, had a diagnosis of migraine with or without aura, and were consecutively treated with erenumab for chronic or high-frequency (≥8 monthly headache days) episodic migraine. Information on triptan use prior to erenumab was collected via a data collection form administered during a telephone interview.

“Patients who reported use of at least one triptan for at least 3 migraine attacks were considered triptan users,” researchers wrote. “Triptan users were classified as ‘triptan responders’ if they were headache-free within 2 hours after treating at least 3 migraine attacks with one triptan; the remaining patients were classified as ‘triptan non-responders.’” Non-responders were asked about decreased response over time and whether the efficacy of triptans improved after erenumab treatment began.

‘Erenumab responders’ were defined as patients who reported a mean ≥ 50% reduction in monthly migraine days from baseline to months 4 to 6 of treatment.

Of the 105 patients treated with erenumab who answered the data collection form, 91 (86.6%) were considered triptan users. Of these patients, 58 (63.7%) were erenumab responders, 33 (32.3%) were erenumab nonresponders, 73 (80.2%) were triptan responders, and 18 (19.8%) were triptan non-responders. Researchers found no significant differences in baseline characteristics between the erenumab responders and nonresponders, apart from triptan use.

Analyses revealed:

• Among erenumab responders, 51 (87.9%) were triptan responders while among erenumab non-responders, 22 (66.7%) were triptan responders
• The odds ratio (OR) of being an erenumab responder was 3.64 (95% CI, 1.25–10.64) for triptan responders compared with nonresponders (P  =  .014)
• The OR of being an erenumab responder was 0.78 (95% CI, 0.33–1.83) for patients reporting triptan wear-off compared with those not reporting triptan wear-off (P  =  .565)
• After starting erenumab treatment, 52 patients (57.1%) continued using triptans; 36 of them (69.2%) were erenumab responders and 16 (30.8%) were erenumab nonresponders
• The proportion of patients reporting an improvement in triptan effectiveness was similar in erenumab responders and erenumab nonresponders (52.8% vs 62.5%; OR 0.67; 95% CI, 0.20–2.24; P  =  .265)

Although the findings may be used in clinical practice to advise patients about their chances of response to erenumab, researchers cautioned previous response to triptans alone should not represent a strict criterion to select patients for erenumab, given many triptan non-responders did respond to erenumab.

A limited number of participants, in addition to the potential for recall bias in the study’s design, mark limitations.

Overall, “improving responsiveness to acute medication is a goal of migraine prevention and might be an additional parameter to test the efficacy of preventative drugs,” researchers concluded. “This information is relevant to improve our understanding of migraine and its treatments and to predict the efficacy of migraine-specific preventatives.”

Reference

Frattale I, Caponnetto V, Casalena A, et al. Association between response to triptans and response to erenumab: real-life data. J Headache Pain. Published online January 6, 2021. doi:10.1186/s10194-020-01213-3