A systematic review and pooled analysis by the International Headache Society found that all four anti-CGRP monoclonal antibodies are superior to placebo for reducing monthly migraine days in both episodic and chronic migraine, with no major differences between them.
All 4 anti-CGRP mAbs superior to placeboEptinezumab, erenumab, fremanezumab, and galcanezumab all reduce monthly migraine days in episodic and chronic migraine
What the researchers found
All four anti-CGRP monoclonal antibodies (eptinezumab, erenumab, fremanezumab, and galcanezumab) are superior to placebo for reducing monthly migraine days in both episodic and chronic migraine patients. The pooled analysis of randomized controlled trials showed consistent efficacy across all four treatments, with no major differences between them.
The evidence was assessed using the rigorous GRADE methodology and compiled into standardized evidence tables. These tables evaluate both the efficacy (reduction in migraine days) and safety profile of each antibody, providing a comprehensive evidence base for clinical guideline development.
Why it matters
This is not just another review — it's the International Headache Society's official evidence assessment designed to inform clinical guidelines worldwide. Having a standardized, rigorous comparison of all four anti-CGRP antibodies helps clinicians and guideline committees make evidence-based recommendations. The finding that all four are effective with no major differences gives patients and doctors flexibility in choosing based on individual factors like dosing preference and insurance coverage.
How the study worked
The researchers formulated PICO (patient/population, intervention, comparison, outcomes) questions and performed a systematic literature search for randomized controlled trials of all four anti-CGRP monoclonal antibodies. They conducted a pooled analysis using RevMan 5.4 software, using risk ratios for dichotomous outcomes and mean differences for continuous outcomes. Evidence quality was assessed using GRADE methodology, which rates certainty of evidence from very low to high. Serious adverse events were reported separately in study characteristic tables.
What this study cannot tell us
The abstract does not provide specific numerical results from the pooled analysis (e.g., exact reduction in migraine days). Long-term safety outcomes beyond the duration of the included trials were not the focus. The review focused on placebo-controlled trials, so head-to-head comparisons between the antibodies were indirect rather than direct. Real-world effectiveness may differ from clinical trial efficacy.
How to read the evidence
This is a systematic review and pooled analysis of randomized controlled trials — one of the highest levels of evidence in clinical research. The use of GRADE methodology by the International Headache Society adds additional rigor and standardization to the evidence assessment.
When this study was published
Published in 2023, this is a recent and highly authoritative evidence review. All four anti-CGRP antibodies included are currently approved and in clinical use, making this review directly relevant to current practice.
The bigger picture
Anti-CGRP monoclonal antibodies have transformed migraine prevention since their approval starting in 2018. This systematic review provides the definitive evidence synthesis needed for treatment guideline development worldwide. As healthcare systems evaluate which medications to recommend and reimburse, having standardized GRADE evidence tables from the International Headache Society carries significant weight in clinical policy decisions.
Questions still open
- Are there meaningful differences between the four antibodies in specific patient subgroups that the pooled analysis may have missed?
- How do the long-term safety profiles compare across these four antibodies beyond clinical trial durations?
- What is the optimal approach for patients who don't respond to one anti-CGRP antibody — should they try another?
Common questions
What are anti-CGRP monoclonal antibodies and which ones are available?
If all four antibodies work equally well, how should patients choose between them?
Read the original research
Efficacy and safety of monoclonal antibodies targeting CGRP in migraine prevention. GRADE tables elaborated by the ad hoc working group of the International Headache Society.
Cephalalgia : an international journal of headache, 43(10), 3331024231206162
Citation
Aleksovska, Katina; Hershey, Andrew D; Deen, Marie; Icco, Robert de; Lee, Mi Ji; Diener, Hans-Christoph. (2023). Efficacy and safety of monoclonal antibodies targeting CGRP in migraine prevention. GRADE tables elaborated by the ad hoc working group of the International Headache Society.. Cephalalgia : an international journal of headache, 43(10), 3331024231206162. https://doi.org/10.1177/03331024231206162