The U.S. Food and Drug Administration (FDA) revolutionized migraine treatment when the agency approved a new class of drugs in 2018: calcitonin gene-related peptide monoclonal antibodies, or CGRP mAbs.

With minimal side-effects, these new drugs have proven effective at preventing both chronic and episodic migraines. In some cases, they are even replacing the use of botulinum toxins in migraine treatment.

Unlike traditional oral medications (or botox injections), CGRP mAbs are the first prophylactic drugs to directly target a migraine-specific pathway. They work against calcitonin gene-related peptide (CGRP), a neuropeptide found in the trigeminovascular system that is elevated during migraines.

The first CGRP mAb, erenumab (Aimovig™), was approved by the FDA in May of 2018, followed by Fremanezumab-vfrm (AJOVY™), and then galcanezumab (Emgality™). All three of these drugs can be self-injected. The FDA approved eptinezumab-jjmr (Vyepti™), which is given intravenously, in 2020.

We reached out to New York headache specialist Dr. Heidi Schwarz to see how this new class of drugs is being used in clinics today.

Putting Into Practice

Oral medications, the traditional first line of treatment for migraines, are not always effective and sometimes have adverse side effects. Schwarz said many patients go through five or six oral treatments before they are introduced to CGRP mABs.

This has changed, Schwarz said, and she and her team are ordering the injections sooner.

“CGRP monoclonal antibodies have been truly game changers for people with either migraines or cluster headaches,” Schwarz said.

While all the drugs tend to have a similar side-effect profile, the efficacy varies by patient. In addition, costs can vary and may be limited by insurance companies.

“Vyepti may have more efficacy than the self-injections,” Schwarz said. “But it requires a visit to the office and an IV placement, which is more inconvenient for the patient and has more limited insurance coverage.”

“On the other hand,” she added, “I have seen it make a significant difference in some patients who have failed the self-injections.”

Better than Botox?

Botox (physician injected) is also successfully used to prevent chronic migraines. In combination with CGRP mABs, botox can be even more effective, Schwarz said.

Sometimes CGRP mAbs do prove to be the better choice for patients, she added. This is mainly because CGRP mABs are less painful and self-administered. This is “self-empowering” for patients and easier, she said.

Self-administration has proven to be a big advantage during the COVID-19 pandemic. Many patients receiving regular botox injections have had an interruption in treatment and their headaches worsen, Schwarz said.

Special thanks to Heidi Schwarz, MD, Professor of Clinical Neurology, University of Rochester Medical center, Rochester, NY, who specializes in headache medicine.