Anti CGRP Treatments for Migraine

Groundbreaking News for Migraine Sufferers - Discussing the New Anti CGRP Migraine - Treatment Options

What is CGRP?

CGRP stands for calcitonin gene-related peptide, and it is a protein that is released around the brain. When CGRP is released, it causes intense inflammation in the coverings of the brain (the meninges), and for most migraine patients, causes the pain of a migraine attack. In fact, if you give CGRP by an intravenous method to a person with migraine, within four hours, most of them will get a migraine. That’s the basis of all the new treatments. 1

What are Anti CGRP Treatments and how do they work?

Anti CGRP treatments - called Monoclonal Antibodies - bind to calcitonin gene-related peptide (CGRP) to block the pain experienced by migraine sufferers. CGRP causes headaches in migraine patients, and we know that CGRP levels are elevated during migraine. Therefore targeting CGRP makes perfect sense. 2

Studies show Anti CGRP treatments often benefit migraineurs who previously failed to respond to preventive therapy

The first monoclonal antibody to be approved called erenumab (Aimovig) was studied in people who had already had two to four preventive medication failures, and I mean complete failures. These were people that had taken antidepressants, anti-epilepsy drugs, anti-blood pressure drugs that were supposed to be effective for migraine prevention, and they had not worked at all. Then, they were given the monoclonal antibody, and it seemed to work. The other monoclonal antibodies are also being studied for people who have had a lack of success with their previous preventive treatments, and they also very good in terms of likelihood of success, even though people have had a lack of success with previous treatments.3

Monoclonal Antibody Types and CGRP Oral Antagonists

CGRP Antibodies

Oral CGRP Antagonists

How fast can I expect to see Results?

Studies show that the effects of CGRP MABs can be observed over the first few weeks after the first injection. 4

Dr Amaal Sterling of the Mayo Clinic in Phoenix, Arizona suggests that "In one study, patients saw results in less than one week—a dramatic reduction from the two to three months that it can take for other oral migraine medications to deliver results." 5

Benefits & Drawbacks (according to experts)

Benefits

  • these drugs are very well tolerated, and have few side effects
  • Dr. Stewart Tepper notes that "there doesn’t seem to be any drug interactions that we know of with these monoclonal antibodies and other treatments. People would still be able to use their acute treatments when a migraine breaks through because for most people, these are not going to completely eliminate migraines. They’re going to help with frequency, severity, and duration." 6

Drawbacks

  • In some cases, the molecule involved in treatment is so large that it can’t be delivered in pill form. Instead, it has to be administered with an injection or an infusion using an IV (U.S product). However, given that the treatment schedule ranges from every two weeks to once every three months, those who have a hard time remembering to take a daily pill might consider this a benefit. 7
  • some sufferers experience soreness around the injection site

Eptinezumab (IV Infusion) - U.S. (not expected to come to Canada)

Eptinezumab (formerly known as ALD403) is our pivotal-stage monoclonal antibody (mab) that inhibits calcitonin gene-related peptide (CGRP), a neuropeptide that plays an important role in migraine pathophysiology.8

Eptinezumab is currently in late-stage clinical development and, if approved it will be the first-to-market infusion therapy for migraine prevention. 8

Alder Biopharmaceuticals claims that this drug is not expected to come to Canada.

Headache Specialists' Comments

Dr. Amaal Starling, MD. FRCP (C) Assistant Professor of Neurology, Mayo Clinic, Phoenix, Arizona

Results from the clinical trials involving anti-CGRP antibodies have shown that about 50 percent of patients will have at least a 50 percent reduction in migraine days.

"If you think about someone who has 20 migraine days per month, they have a 50 percent chance of having 10 or less migraine days," Dr. Starling says. "We think that there are even these super-responders who have a 75 percent response rate, as well as super-super-responders who actually go into remission."

Dr. Elizabeth Leroux, MD, FRCPC, Clinical Associate Professor, Neurology - Headache Neurologist, Calgary, Alberta, Co-founder: Migraine Canada

Currently, available migraine preventatives are not sufficient. Up to 80% of chronic migraine patients end up stopping them for lack of efficacy or side effects. For the first time, we have a preventative approach that is based on science, targets one of the causes of migraine, is effective and has few side effects. This may change the way we see migraine in general.

Dr. Stewart Tepper, MD, FRCP (C), Professor of Medicine (Neurology), Dartmouth-Hitchcock Medical Center, Dartmouth Headache Centre, Hanover, New Hampshire

These drugs are extremely well tolerated. In fact, for most people, they don’t seem to have significant side effects other than those who choose the injection version, to experience some pain at the injection site.


To stay up-to-date on this fast-moving area of science I strongly recommend the following professional website. Please note that membership is free. World experts weigh-in on this topic. www.cgrpforum.org

References

  1. American Migraine Foundation, Dr. Stewart Tepper - What is CGRP?
  2. Teva Canada
  3. Dr. Stewart Tepper, What to know about the New Anti CGRP Migraine treatment options, May 2018
  4. Canadian Headache Society/Migraine Canada - CGRP Antibodies for Migraine - Handout
  5. Dr. Amaal Starling, Assistant Professor of Neurology at the Mayo Clinic in Phoenix, Arizona
  6. Dr. Stewart Tepper, Facebook Live Recap - CGRP Antiboodies for migraine
  7. Dr. Amaal Starling, Assistant Professor of Neurology at the Mayo Clinic in Phoenix, Arizona
  8. Alder Biopharmaceuticals - Eptinezumab, IV infusion

The opioids (narcotics) cause progression of the illness (Chronic Daily Headache), not termination, and will actually make the individual much worse over time. It is easier and quicker to give the patient a pain killer than to "get into the trench" and try solve the problem. Patients with chronic daily headache require time, diligence, and frequent access from their physician.

Interview: Dr. Joel Saper, MHNI
-from the book Chronic Daily Headache

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