Why CGRPs are failing your chronic migraine patients—and what to do about it
Key Takeaways
Industry Buzz
“When patients discontinue them, it is due to side effects, not seeing a benefit after 3 months of use, difficulty with the injections… or if the monthly cost of the medication is too high.” — Leon Moskatel, MD, clinical assistant professor and expert in headache medicine at Stanford
“Insurance is requiring [my patient] to try two other medications for 3 months each, which might worsen her migraine disease for the next 6 months or more. This is completely unnecessary pain, suffering, and disability.” — Amaal J. Starling, MD, associate professor of neurology, Program Director of the Headache Medicine Fellowship at Mayo Clinic
CGRP-targeted therapies are considered an essential treatment option for patients with migraine. Yet discontinuation of the drugs among some patients can be as high as 71%.[]
Experts say the rates of discontinuation can be due to a number of factors.
“We find that when patients discontinue them, it is due to side effects, not seeing a benefit after 3 months of use, difficulty with the injections (for erenumab, galcanezumab, and fremanezumab), or if the monthly cost of the medication is too high because of insufficient insurance coverage,” Leon Moskatel, MD, a clinical assistant professor of Adult Neurology and an expert in headache medicine at Stanford, tells MDLinx.
The biggest challenge
Experts note that discontinuation of CGRP-targeted therapies is not always the choice of the patient or specialist, but often due to difficulties with insurance.
“Just this week, one of my patients who has been doing quite well on her CGRP monoclonal antibody for several years was denied the medication by her new insurance company,” Amaal J. Starling, MD, an associate professor of Neurology and Program Director of the Headache Medicine Fellowship at Mayo Clinic, tells MDLinx. “The insurance is requiring her to try two other medications for 3 months each, which might worsen her migraine disease for the next 6 months or more."
"This is completely unnecessary pain, suffering, and disability."
— Amaal J. Starling, MD
No one-size-fits-all migraine treatment
CGRP-targeted therapies are among the evidence based treatment recommendations from the American Headache Society.[]
They are indicated for the treatment of moderate or severe migraine attacks or mild to moderate attacks that respond poorly to nonspecific therapies like NSAIDs.[]
Dr. Moskatel notes there are many steps physicians can take to assist their patients who may need to discontinue a certain type of CGRP. “If a patient does not see benefit with one CGRP-targeted medication, then we do consider one of the others, as there is evidence to support that patients may respond to one CGRP-targeted therapy and not another,” he says.
“When you rigorously look at the efficacy and tolerability of the different CGRP-targeted therapies, we see that there is not a substantial difference in efficacy and tolerability between the different options. As a result, the best option is the one that is tailored to the patient," he continues. "For example, a patient who would prefer not to inject themselves may benefit from an oral gepant, while a patient who prefers a low frequency treatment may be more interested in the quarterly schedule offered by two of the CGRP monoclonal antibodies.”
Fremanezumab and eptinezumab offer quarterly dosing schedules. While fremanezumab is a administered via subcutaneous injection, eptinezumab is administered as an IV infusion, making it a fit for patients who prefer a non-injectable, low-frequency treatment.
Generally, CGRP-targeted therapies are well tolerated, and there is no one size fits all approach. “Every person with migraine is an individual—different treatment options work for different people. If there are side effects, like constipation from a receptor blocker, switching to a ligand blocker may be a good option,” Dr. Starling says.
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