erenumab for the prevention of chronic migraine

Last edited 12/2021 and last reviewed 10/2022

Erenumab is a human anti-CGRP (calcitonin gene related peptide) receptor monoclonal antibody that has been developed for migraine prevention. Erenumab has demonstrated clinical efficacy in episodic migraine and chronic migraine, reducing both monthly migraine days (MMDs) and acute migraine-specific medication (AMSM) use:

• CGRP levels were found to be elevated during a migraine attack in plasma, saliva and CSF samples from patients
• intravenous infusion of CGRP has been shown to trigger a migraine-like attack without aura in about 60% of sufferers
• triptans, 5-HT1B/D receptor agonists and migraine specific treatments, have been shown to reduce CGRP plasma levels in migraine patients, but not in healthy subjects
• clinical trials data suggest superiority of the CGRP mAbs (monoclonal antibodies) to placebo in terms of prevention of migraine symptoms, migraine-specific quality of life and headache related disability
• treatment-related side effects overall did not differ significantly from placebo and discontinuation rate due to side effects has been low across the clinical trials, perhaps in view of their peripheral mode of action

NICE state:

• Erenumab is recommended as an option for preventing migraine in adults, only if:

  • they have 4 or more migraine days a month
  • at least 3 preventive drug treatments have failed
  • the 140 mg dose of erenumab is used
    
    
• stop erenumab after 12 weeks of treatment if:
  • in episodic migraine (less than 15 headache days a month) the frequency does not reduce by at least 50%
  • in chronic migraine (15 headache days a month or more with at least 8 of those having features of migraine) the frequency does not reduce by at least 30%

Previous studies indicate patients with migraine (MG) with aura may respond differently to acute therapies. A post hoc analysis (n=2682) found reduced MG frequency and acute MG-specific medication days with erenumab whether or not patients had MG with/without history of aura (3)

Reference:

• Andreou AP, Fuccaro M, Lambru G. The role of erenumab in the treatment of migraine. Ther Adv Neurol Disord. 2020;13:1756286420927119. Published 2020 May 27. doi:10.1177/1756286420927119
• NICE (March 2021). Erenumab for preventing migraine
• Ashina M, Goadsby PJ, Dodick DW, et al. Assessment of Erenumab Safety and Efficacy in Patients With Migraine With and Without Aura: A Secondary Analysis of Randomized Clinical Trials. JAMA Neurol. Published online December 20, 2021. doi:10.1001/jamaneurol.2021.4678