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Content Update

March 6, 2018

CGRP Monoclonal Antibodies for Prevention of Migraine Headache: Calcitonin gene-related peptide (CGRP) is a neuropeptide involved in central and peripheral vasodilation and nociception; agents that inhibit the CGRP receptor or the ligand itself have been shown to decrease migraine headache frequency in studies lasting 3 to 6 months. Three CGRP monoclonal antibodies (mAbs) are under review by the U.S. FDA for prevention of migraine headaches: erenumab, fremanezumab, and galcanezumab. These macromolecules act preferentially in the periphery, with only small amounts crossing the intact blood brain barrier, reducing the potential for adverse CNS side effects experienced with current prophylactic drugs (eg, β-blockers, antiepileptic drugs). Their long half-lives also allow for once-monthly or possibly quarterly administration (albeit by subcutaneous injection), which may improve adherence. The results of long-term studies of 12 months or more are pending and will offer further insights into the prophylactic efficacy and safety of these novel agents.


For the chapter in the Wells Handbook, please go to Chapter 54. Headache: Migraine and Tension-Type.



  • image Acute migraine therapies should provide consistent, rapid relief and enable the patient to resume normal activities at home, school, or work.

  • image A stratified care approach, in which the selection of initial treatment is based on headache-related disability and symptom severity, is the preferred treatment strategy for the migraineur.

  • image Strict adherence to maximum daily and weekly doses of anti-migraine medications is essential.

  • image Preventive therapy should be considered in the setting of recurring migraines that produce significant disability; frequent attacks requiring symptomatic medication more than twice per week; symptomatic therapies that are ineffective, contraindicated, or produce serious side effects; and uncommon migraine variants that cause profound disruption and/or risk of neurologic injury.

  • image The selection of an agent for headache prophylaxis should be based on individual patient response, tolerability, convenience of the drug formulation, and coexisting conditions.

  • image Each prophylactic medication should be given an adequate therapeutic trial (usually 6 months) to judge its maximal efficacy.

  • image A general wellness program and consideration of headache triggers should be included in the management plan.

  • image After an effective abortive agent and dose have been identified, subsequent treatments should begin with that same regimen.

Headache is one of the most common complaints encountered by healthcare practitioners and among the top five principal reasons given by adults 18 to 44 years of age for visiting US emergency departments.1 It can be symptomatic of a distinct pathologic process or can occur without an underlying cause. In 2013, the International Headache Society (IHS) updated its classification system and diagnostic criteria for headache disorders, cranial neuralgias, and facial pain2 (Table 61-1). Designed to facilitate headache diagnosis in clinical practice and research, the IHS classification provides more precise definitions and standardized nomenclature for both the primary (tension-type, migraine, and cluster headache) and secondary (symptomatic of organic disease) ...

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