With all the recent news in migraine treatment, it might be difficult to keep up! 2018 has been an exciting year for those waiting for something new to prevent migriane, and that patience has paid off–there are now three CGRP blockers available for the prevention of migraine:
Ajovy™ (fremanezumab-vfrm), approved on September 14th
Emgality™ (galcanezumab-gnlm), approved on September 27th
CGRP blockers are the latest development in migraine prevention, offering new hope to the millions who live with the debilitating effects of migraine. While all of these new products target the CGRP process, there are some differences between these products.
(Information in chart last updated on 10/18/18.)
How do CGRPs prevent migraine?
CGRP (calcitonin-gene-related peptide) is a protein that acts like a neurotransmitter (a chemical messenger) throughout the brain and body. The role of CGRP in migraine has been know since the mid-1980s, but it has been difficult to develop drugs targeting CGRP.
CGRP and CGRP receptors are found in large numbers in the trigeminal system, the sensory nerves that supply the head and neck. As well, CGRP is known to be involved in the dilation of veins (vasodilation) and in the sensory nervous system, both of which are impacted by migraine. Researchers have discovered that the level of CGRP is increased during a migraine attack. In people with chronic migraine, CGRP seems to be chronically elevated.
All three medications are monoclonal antibodies targeting the CGRP pathway. To date, monoclonal antibodies have been used to treat a number of different chronic health conditions. Monoclonal antibodies work both indirectly, by activating our own immune system, and directly by binding to proteins or parts of a protein (peptide) or receptors.
To understand how the new medications disrupt the CGRP process, consider the lock-and-key analogy, with the CGRP peptide acting as the key and the receptor acting as the lock.
Aimovig blocks the lock, which allows less of the CGRP protein to bind to the receptors.1
Ajovy and Emgality attach to the key, distorting the CGRP protein so that less of it can connect to the receptors.2,3
How are CGRPs taken?
All three CGRP blockers are administered subcutaneously, an injection given under the skin. Aimovig is available in a self-administered autoinjector, while Ajovy comes in a prefilled syringe. Emgality is available in both a self-administered autoinjector and a prefilled syringe. These CGRP blockers may be administered by the patient, a caregiver, or a healthcare professional.1-3
What are the CGRP dosing options?
Aimovig is given monthly. The recommended starting dosage is 70 mg once monthly, although some patients may benefit from a dosage of 140 mg once monthly.1
Ajovy offers two different dosing options: 225 mg given monthly or 675 mg given every 3 months (quarterly).2
With Emgality, the first dose is a “loading dose” of 240 mg (given as two injections). Afterwards, the dose is 120 mg given once a month.3
As with any medication, the best dosage for you should be determined with your doctor.
CGRP cost and assistance programs
All three CGRP blockers are similarly priced, although coverage may vary depending on an individual’s insurance plan or other support programs.
Aimovig cost and assistance programs
Aimovig (marketed by the partnership of Amgen and Novartis) is priced at $6,900 per year, which works out to $575 a month. Aimovig offers two months of free samples and Amgen has a program that can provide up to a year’s supply of the drug for some people who may have difficulties getting insurance coverage.
Ajovy cost and assistance programs
Ajovy (manufactured by Teva) is similarly priced at $575 a month or $6,900 a year, although the quarterly dosing offers another option: three injections for $1,725.4 While the details on Ajovy’s assistance program are not yet known, Teva has stated they will have an assistance program that can bring the out-of-pocket expenses to $0 for certain patients.4
Emgality cost and assistance programs
The list price of Emgality (manufactured by Lilly) is also $575 monthly, or $6,900 annually.5 Lilly is offering a year’s worth of Emgality treatment to those with commercial insurance as part of their patient assistance program. Offering the product free for a year also gives the company time to work with insurance companies on coverage.5
Will CGRPs work for me?
Since there were no clinical trials comparing these three different anti-CGRPs drugs to each other, there is no way to know which might be more effective. For now, the clinical trial data shows very similar results in terms of efficacy, tolerability, and safety. Each of these CGRP blockers has demonstrated effectiveness in reducing the number and/or severity of migraine days in adults with chronic or episodic migraine.1-3
Despite the devastating impact of migraine for people with the condition, only about 10 percent of people with migraine are currently taking a preventive treatment.
While these new anti-CGRP medications may help prevent migraine for some people, others may not experience a benefit. Like all medications, they may work for some and not for others. While the CGRP pathway is a novel and exciting new development, it may not be the answer for all who have migraine. Each individual should discuss with their doctor whether a CGRP blocker is right for them, as well as if there are other medications that may help with the relief of other migraine symptoms.
Aimovig prescribing information. Available at https://pi.amgen.com/~/media/amgen/repositorysites/pi-amgen-com/aimovig/aimovig_pi_hcp_english.ashx. Accessed 10/4/18.
Ajovy prescribing information. Available at https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/761089s000lbl.pdf. Accessed 10/4/18.
Emgality label. Available at http://pi.lilly.com/us/emgality-us-ppi.pdf. Accessed 10/4/18.
Beasley D. U.S. regulator approves Teva migraine drug, shares rise. Available at https://www.reuters.com/article/us-teva-migraine-fda/u-s-regulator-approves-teva-migraine-drug-shares-rise-idUSKCN1LU2TU. Accessed 10/4/18.
Lilly's Emgality™ (galcanezumab-gnlm) Receives U.S. FDA Approval for the Preventive Treatment of Migraine in Adults. PR Newswire. Available at https://www.prnewswire.com/news-releases/lillys-emgality-galcanezumab-gnlm-receives-us-fda-approval-for-the-preventive-treatment-of-migraine-in-adults-300720720.html. Accessed 10/4/18.