Anti-CGRP monoclonal antibodies offer migraine sufferers a faster-acting, better-tolerated alternative to conventional preventive treatments, but their high cost demands careful patient selection.
#1 cause of disability in under-50sMigraine is the most common neurological disorder and the leading cause of disability in people under 50 worldwide, underscoring the urgency for better preventive treatments.
What the researchers found
Three first-in-class anti-CGRP monoclonal antibodies — erenumab, galcanezumab, and fremanezumab — have been approved for migraine prevention based on consistent phase 2 and phase 3 clinical trial data demonstrating both safety and efficacy for episodic and chronic migraine. These therapies offer advantages over conventional preventive treatments including rapid onset, sustained efficacy, a placebo-like safety profile, and no pharmacological interactions. However, the high cost of anti-CGRP mAbs makes careful patient selection essential to optimize treatment effectiveness and resource allocation.
Why it matters
Migraine is the leading cause of disability in people under 50, yet existing preventive drugs were originally developed for other conditions and have unclear mechanisms in migraine. Anti-CGRP monoclonal antibodies represent the first treatments specifically designed to target migraine pathophysiology, potentially transforming care for patients who fail conventional therapies.
How the study worked
This is an expert review article that synthesizes data from phase 2 and phase 3 clinical trials of three anti-CGRP monoclonal antibodies (erenumab, galcanezumab, and fremanezumab), evaluates the shortcomings of current preventive treatments, and discusses strategies for optimizing patient selection.
Who was studied
Patients with episodic and chronic migraine who are candidates for preventive treatment
What this study cannot tell us
As a narrative review rather than a systematic review or meta-analysis, the article relies on the authors' expert interpretation of existing trial data. Specific outcome numbers from the individual trials are not detailed in the abstract. Long-term safety and real-world effectiveness data were limited at the time of publication.
How to read the evidence
This is an expert review article that summarizes phase 2 and phase 3 clinical trial data rather than presenting original research. While it draws on high-quality trial evidence, the review format and narrative synthesis place it below primary trial reports in the evidence hierarchy.
When this study was published
Published in 2019, shortly after the first anti-CGRP mAbs were approved. Since then, additional real-world data and a fourth CGRP-targeting antibody (eptinezumab) have emerged, though the core conclusions about patient selection remain relevant.
The bigger picture
The approval of anti-CGRP monoclonal antibodies marked a turning point in migraine medicine — the first therapies designed specifically to target migraine biology rather than repurposing drugs from other fields. This shift toward mechanism-based treatment opens the door for more precise, personalized migraine care, though health systems must balance the promise of these therapies against their cost through informed patient selection strategies.
Questions still open
- Which specific patient characteristics best predict a strong response to anti-CGRP monoclonal antibodies versus conventional preventive treatments?
- How do the long-term costs of anti-CGRP therapies compare to the total direct and indirect costs of undertreated or untreated migraine?
- Will real-world effectiveness data match the favorable safety and efficacy profiles seen in controlled clinical trials?
Common questions
What is CGRP and why does blocking it help prevent migraines?
Why can't everyone with migraines get these new antibody treatments?
Read the original research
Patient selection for migraine preventive treatment with anti-CGRP(r) monoclonal antibodies.
Expert review of neurotherapeutics, 19(8), 769-776
Citation
Negro, Andrea; Martelletti, Paolo. (2019). Patient selection for migraine preventive treatment with anti-CGRP(r) monoclonal antibodies.. Expert review of neurotherapeutics, 19(8), 769-776. https://doi.org/10.1080/14737175.2019.1621749