EHF anti-CGRP treatment recommendations

Lars Bendtsen | maj 2020 | Neurologi |

Lars Bendtsen
Associate Professor,
Department of Neurology
and Danish Headache Center,
Rigshospitalet Glostrup,
University of Copenhagen,
Co-director of the Danish Headache Center

Co-author of the European Headache Federation (EHF) guideline on the use of anti-CGRP monoclonal antibodies (mAbs) for migraine prevention, Lars Bendtsen presented an overview of the scientific basis for the recommendations.  Scientific basis The European guidelines were put together by a task force of 7 experts from 5 European countries.1 The recommendations were developed to answer 7 clinically important questions on how to use the anti-CGRP mAbs.  For episodic migraine, the evidence included 4 phase 2 studies (one each for eptinezumab, erenumab, fremanezumab and galcanezumab) and 3 phase 3 studies (one each for erenumab, fremanezumab and galcanezumab). The evidence for chronic migraine came from two 2 phase 2 studies (one for erenumab and one for fremanezumab) and two 2 phase 3 studies (one for fremanezumab and one for galcanezumab).   Is treatment with CGRP mAbs effective? It was found that the use of anti-CGRP mAbs reduced the number of migraine headache days with 1-2.5 days per month compared with placebo. Moreover, at least 50% reduction in migraine days was typically seen in 45%-50% of patients on active treatment and in 35%-30% of patients on placebo. Based on this evidence, the EHF guideline strongly recommends the use of erenumab, fremanezumab and galcanezumab.  When to offer treatment? The guideline recommends using erenumab, fremanezumab or galcanezumab in episodic and chronic migraine patients that have failed at least 2 previous preventive medications.  How to manage other preventive treatments when patients are treated with anti-CGRP mAbs? In patients with episodic migraine, oral preventives should be stopped before the use of anti-CGRP mAbs is started unless the patient has a history of chronic migraine. In patients with chronic migraine, oral preventives can be considered to be used in combination with anti-CGRP mAbs. In these patients, onabotulinumtoxin A should be stopped before use of anti-CGRP mAbs is started. This last...