Network Meta-Analysis Ranks Anti-CGRP Migraine Drugs: Fremanezumab Best at 6 Weeks, Erenumab at 12 | Research

The takeaway

Network meta-analysis of anti-CGRP migraine drugs found fremanezumab 900mg most effective at 6 weeks for both chronic and episodic migraine, while erenumab 140mg was most effective at 8 and 12 weeks.

Timing matters for drug choice
Fremanezumab worked fastest (best at 6 weeks) but erenumab provided superior sustained effect (best at 8-12 weeks) — drug choice may depend on how quickly relief is needed

What the researchers found

At 6 weeks: fremanezumab 900mg most effective (SMD=-0.55). At 8 weeks: erenumab 140mg most effective (SMD=-0.51). At 12 weeks: erenumab 140mg most effective (SMD=-0.48). For chronic migraine: fremanezumab 900mg best at 6 weeks, erenumab 140mg best at 8 and 12 weeks.

Why it matters

Choosing between four similar drugs is difficult without comparative data. This NMA provides evidence-based rankings by timepoint and migraine type, enabling more informed prescribing decisions.

The numbers in context

6wk: fremanezumab 900mg SMD -0.55; 8wk: erenumab 140mg SMD -0.51; 12wk: erenumab 140mg SMD -0.48; drugs: erenumab, eptinezumab, fremanezumab, galcanezumab

How the study worked

Systematic review and network meta-analysis. SCOPUS, PubMed, Cochrane, Embase through January 2019. RCTs of erenumab, eptinezumab, fremanezumab, galcanezumab vs placebo. Efficacy at 6, 8, and 12 weeks. Episodic and chronic migraine analyzed separately and combined.

Who was studied

Episodic and chronic migraine patients from randomized controlled trials

What this study cannot tell us

NMA relies on indirect comparisons. Head-to-head trials between anti-CGRP drugs are limited. Effect sizes are modest. Long-term (>12 week) comparisons not assessed. Dose comparisons limited.

How to read the evidence

Moderate-to-high evidence: network meta-analysis of randomized controlled trials, though indirect comparisons between drugs have inherent limitations.

When this study was published

Published 2021. Data through January 2019. Additional clinical experience has accumulated since, though relative rankings may remain similar.

The bigger picture

As more anti-CGRP drugs compete, comparative effectiveness research becomes essential. This NMA shows that drug ranking depends on the timeframe — suggesting that patient expectations should be set accordingly.

Questions still open

Would fremanezumab maintain its advantage with continued quarterly dosing beyond 6 weeks?
Why does the relative efficacy ranking change over time?
Should drug choice be based on expected treatment duration?

Common questions

Which anti-CGRP migraine drug is best?

It depends on timing needs. Fremanezumab (Ajovy) at 900mg quarterly worked fastest — best at 6 weeks. Erenumab (Aimovig) at 140mg monthly was best at 8-12 weeks for sustained effect. Both work for episodic and chronic migraine.

Should I switch if my anti-CGRP drug isn't working at first?

This NMA shows that some drugs work faster than others. If your drug hasn't worked by 12 weeks, switching may be warranted. But some anti-CGRP drugs that are less effective at 6 weeks become more effective by 12 weeks — patience may pay off.

Read the original research

Efficacy of calcitonin gene-related peptide (CGRP) receptor blockers in reducing the number of monthly migraine headache days (MHDs): A network meta-analysis of randomized controlled trials.

Journal of the neurological sciences, 427, 117505

View on PubMed ↗Publisher’s paper ↗

Citation

Masoud, Ahmed Taher; Hasan, Mohammed Tarek; Sayed, Ahmed; Edward, Harvey Nabil; Amer, Ahmed Mohamed; Naga, Abdelrahman Elshahat; Elfil, Mohamed; Alghamdi, Badrah S; Perveen, Asma; Ashraf, Ghulam Md; Bahbah, Eshak I. (2021). Efficacy of calcitonin gene-related peptide (CGRP) receptor blockers in reducing the number of monthly migraine headache days (MHDs): A network meta-analysis of randomized controlled trials.. Journal of the neurological sciences, 427, 117505. https://doi.org/10.1016/j.jns.2021.117505