Treatment of Migraine Using Monoclonal Antibodies

Migraine Prevention Treatment Algorithm

The American College of Physicians recommends CGRP monoclonal antibodies as second-line options when first-line treatments are not tolerated or provide inadequate response 6, 5
Beta blockers without intrinsic sympathomimetic activity (atenolol, bisoprolol, metoprolol, or propranolol) are considered first-line treatments for migraine prevention 1, 2
Topiramate is a first-line treatment option for migraine prevention 1, 2
Candesartan is a first-line treatment option for migraine prevention 1, 2
Flunarizine is a second-line treatment option for migraine prevention 1, 2
Amitriptyline is a second-line treatment option for migraine prevention 1, 2
Sodium valproate is a second-line treatment option for migraine prevention, but is contraindicated in women of childbearing potential 1, 2, 4

Consider CGRP monoclonal antibodies in patients who have failed or cannot tolerate first-line and second-line preventive medications 1, 2, 5
CGRP monoclonal antibodies are appropriate for patients who are adversely affected by migraine on ≥2 days per month despite optimized acute treatment 1, 2
In Europe, regulatory restrictions limit use to patients in whom other preventive drugs have failed or are contraindicated 1

Fremanezumab can be administered monthly (225 mg) or quarterly (675 mg) via subcutaneous injection 1, 4
Efficacy of CGRP monoclonal antibodies should be assessed after 3-6 months of treatment 2, 5

CGRP monoclonal antibodies are generally not recommended during pregnancy due to limited safety data 4
Preferred preventive options during pregnancy (if needed) are propranolol or amitriptyline under specialist supervision 4
Consider comorbidities and potential adverse effects when prescribing CGRP monoclonal antibodies in older patients 1, 4

Treatment duration: Consider pausing successful preventive treatment after 6-12 months to assess continued need 2
Treatment success can be measured by percentage reduction in monthly migraine days or monthly headache days of moderate-to-severe intensity 2

Abandoning treatment too early - efficacy of CGRP monoclonal antibodies should be assessed only after 3-6 months 2
Failing to consider contraindications - particularly important for fremanezumab in patients with vascular conditions 4
Not monitoring for hypertension during erenumab treatment 5
Using in women of childbearing potential without adequate contraception 4