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What Role Would CGRP Antibodies Play in Treatment of Migraines?

Everywhere I turn, I seem to hear people talking about this exciting new breakthrough treatment for migraines. I wonder why therapy with Calcitonin Gene-Related Peptide (CGRP) has caused so much stir in the migraine community. I had never seen so much excitement regarding a treatment for migraines since Imitrex (Sumatriptan) was first released in the early 1990’s.

Could it be that we are desperate for relief that we are ready to bet everything on this new potential therapy? The answer is a resounding yes!

Why the urgency?

Migraines have been ranked among the top 20 causes of global disability. Despite the many prophylactic treatments currently available to prevent chronic migraines, only about 50% of those who would benefit from preventive treatments currently use these methods. However, in my experience, the use of prophylaxis has less to do with doctor’s inability to diagnose migraines appropriately nor their inability to offer appropriate medications; rather from a patient’s inability to obtain necessary treatments due to financial constraints and barriers imposed by insurances.

How is the CGRP different?

One of the theories behind the cause of migraines suggests the involvement of a specific peptide (CGRP) which is released from the trigeminal nerve which is responsible for modulating pain. This peptide has been found to be elevated during the pain phase of a migraine with a return to normal with migraine resolution. Thus, theoretically by blocking these peptides scientists hope to prevent the pain associated with migraines. This would allow a more specific way of potentially treating the pain accompanied by migraines.

Will CGRP be the end-all be-all?

I don’t think so. Although pain is a major component of a migraneuer’s disability, in my years of living with migraines and treating patients, I have found that the sensory component associated with migraines is most disabling; as I rediscovered the other day when I went out to eat and almost died due to bright lights and loud noises in restaurant. This sensory phenomena tend to originate outside the trigeminal nerve, however.

Moreover, the current medications being evaluated by the FDA are all subcutaneous except one which is an intravenous injection. In my practice, I found patients to be reluctant to use injections except as last resort. Having said this, injectable Imitrex is still the fastest acting and most effective treatment for migraines to date yet it is not widely prescribed nor used by patients who prefer oral compounds. There is an oral form of CGRP currently being tested in clinical trials.

Welcomed addition to migraine treatment options

Although, there is talk about a 20% of chronic migraines improvement with CGRP – this astonishing finding needs to be replicated in a larger population.

Further, we don’t know what the effects of these circulating antibodies will have on the female patient’s reproductive system- since women are at greater risk. Not to mention the cost and availability.

Will these substances change the landscape of migraine treatment – no doubt? But will it single handedly eradicate all migraine or improve the life of all migraneurs? Highly unlikely. It will nonetheless provide a new armamentarium with which to combat migraines- a welcome addition in the treatment of a complex disease.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Migraine.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Parikh SK, and Silberstein SD. CGRP: A new treatment for managing migraine in the clinic is on the horizon. (Feb.2018) Practical Neurology 17(2), 20-22.

Comments

  • Juhan
    3 months ago

    After 15 months in Aimovig I decided it was not working. My doctor wanted me to try Ajoyy next. Insurance denied it twice pushing to Emgality. So Emgality it is, all signed up for my co-pay card and first dose should arrive 9/17. Fingers crossed.

  • Joanna Bodner moderator
    3 months ago

    Our fingers are absolutely crossed for you & we hope Emgality brings you the relief you are waiting waiting for! Do keep us posted if you can. We have a forum page where you can do so if you’d like. You can find it here.

  • Diane Bullock
    3 months ago

    I tried Emgality and it made me worse. My migraines became even more painful. The half life of Emgality is 28 days so I am looking at quite a while before it fully works its way out of my system. I am probably the exception because I have multiple neurological disorders that are genetic in origin. Just know these are not the end all and be all of migraine medications.

  • ninafranco
    5 months ago

    You mention injectable imitrex, which I have used MANY times over the years, even way back when it was the only option as the pills were not available yet. However, I cannot imagine using it regularly for those of us who get migraines frequently, say 15 or more a month. First of all is the cost. Last time I checked, even with insurance, my co-pay was 90 dollars for 2. If I got 10 migraines a month that would be 450. Secondly, I dont like stabbing myself all the time. Thirdly, at least with the pills, which I can get the generic type free, I can decide HOW MUCH I need. Let me explain. I was at work the other day. A sudden weather front moved in, I noticed an aura, and one side of my head started to tingle a bit. I told my boss I needed to go to my car. I took out a 100mg sumatriptan pill I had in the car, and bit off a corner, probably about 25-30 mgs. That was enough to stop the migraine cold, and I have been fine ever since. I defiantly would not have wanted to waste a 90 dollar injection on a maybe migraine. So what would have happened was I would have ignored all the symptoms, got really sick and lost a workday. or two or three. I have been on Aimovig for a month and a half now and the almost migraine has been my only brush with migraines. At least with Aimovig you only inject yourself once a month, it is an autoinjector so it is almost foolproof, and it really does not hurt, just a tiny pinch. But injectable Imitrex is not an option for me. I have used it on occasion when I have woken up with a huge migraine with vomiting and therefore cannot keep down a pill. I just started on a program that provides me with free Aimovig, thank goodness!

  • maria.deleon moderator author
    5 months ago

    Ninafranco- thank you for sharing – i absolutely agree that injections are not the most fun. plus i am so thrilled that you got good control with aimovig – i have heard that company has worked hard to make it accessible and affordable. That is a plus. imitrex injection, as an aside, is not meant to be used daily not even weekly – the goal is to stop the migraine in its tracks so it does not develop so like when you first would feel symptoms come on- and meant to be used with prohylactic meds when there were many headaches. i personally loved the nasal spray because almost as quick as injection without having to stab your self and does not interrupt work or activities. i believe you hit on the biggest problem migraneurs have is cost and number of pills allocated- so yes most people like yourself worry and fret that they will be “wasting” a pill or injection on any regular headache and save for so called bad headaches but my experience is as doctor and patient that if you treat the headache as if it were the worst headache then you will not only break super quick but also avoid brain reorganization making it more sensitive to pain. e.g. when i worked i had endless access treatment so if i had a migraine I could always get treatment however, when the cost became exuberabt for those 9 pills initially i felt like all my patients wanting to save the precious pills for “bad or severe headache” all that it happen is i became more headachy, morte sensitive and took longer to break when for all my life i could take a small dose and break cycle. once i realized i had started doing what i always said not to i began again using the medicine as i always had take as soon as any symptoms of migraine whether nausea, light/ noise sensitivity and or headache and headaches reverted back to old pattern of responding fast and never have i ever run out of pills before next refill. Maria De Leon/ moderator/ patient advocate

  • GildaT
    5 months ago

    Are the CRGP’s still contraindicated for those of us with HM? And what about those with autoimmune disorders? In the clinical trials, HM folks were totally refused for any of the studies from any of the companies and any stage of the trials. And those with heart conditions of any kind are shoved to the side with triptans / DHE, leaving only the E.R. and narcotics for a rescue, neither being a “good option” and both being a horrid situation, especially for those of us that have walked this walk for over 25+ years. Botox is somewhat helpful, though pricey – and while the cost of the Botox seems to be going down, the cost for injection is rising, at least in rural, small town USA – 2+ hours from a city of any size and 4 – 6 months to get into a neuro to get that done.

  • Diane Bullock
    3 months ago

    Gildan T, I have HM. My neurologist put me on the CGRP Emgality and it made me significantly worse. If you are sensitive to Sulfur you should know that it is in all the CGRP Meds. I have been at home in bed since April because the migraines have been so horrible. I only took 2 months of injections then I stopped. I have chronic daily migraines as well as HMs but am usually able to get out some mornings for groceries runs; I have had to resort to grocery delivery. I would wait until there is more data; this went to market too fast in my opinion.

  • maria.deleon moderator author
    5 months ago

    GildaT- i understand your plight completely. i have other medical issues which prevent me often times in being included in studies. As a doctor, i totally understand not putting a person at risk by potentially exacerbating underlying problems or causing more harm. i would love to try these meds but with my other illnesses i will not – perhaps in time – every drug has pre clinical and post marketing phases – this means that once they are released to entire population inevitably we will begin to see how people respond and perhaps in time we will find that people like yourself which have HM or cardiac issues do respond without having other side effects or problems – time will only tell be patient -in regards to botox perhaps discuss with physician or your insurance if it would be cheaper for you to acquire medicine on your own through specialty pharmacy? plus remember that botox if done properly typically improves migraines any where from 3- 6 months ( in my experience 4-6months ) so that means only 2 times a year expense- best of luck. Maria De Leon/ moderator/patient advocate/author

  • Diane Fox
    2 years ago

    I am desperate for a preventative that works since none of them have in the 15 years that I have been trying. I did the Teva CGRP clinical trial and it worked so well for the first 3 months. Don’t know if I got high dose, low dose or placebo. Whatever it was it worked great. 1 or 2 migraines in 3 months. Miraculous! I went in to the next phase of the trial that lasted a year. I was getting drug but don’t know which dose. I went back to my 2-3 migraine a week pattern. I was so disappointed because the studies are so promising for this drug. I will try it again when it comes to the market

  • looking4OPH
    2 years ago

    Just completed the Rimegepant ODT abortive trial. This one has had much less visibility. In a recent investor webcast during AANAM, one of the experts said that this class could changed the landscape of treatment by blurring the lines of preventative vs. abortive.

  • Diane Fox
    2 years ago

    How did it work for you? I am really excited about this. Imitrex works for me but the side effects are horrendous. I am getting a little older and I’m not sure how long my Dr will prescribe triptans due to possible effects on the heart.

  • maria.deleon moderator author
    2 years ago

    Looking 4oph…thank you for sharing info..not familiar with this…will look and comment.did you have relief so far? Thnaks
    Happy mother’s day everyone! Maria deleon/ author/moderator/patient advocate

  • maria.deleon moderator author
    2 years ago

    Krgrif, i hear exactly what you are saying ..treat8ng migraines are extremely costly not just financially but also physically and emotionally. I will be so glad when we find better and crossing fingers for less expensive treatments ( although on my part not holding my breath) at least this new class can offer us new hope especially excited about having an oral agent on the list) . Take care and thank you for comments
    Maria de León/author/ patient advocate

  • krgrif
    2 years ago

    I personally don’t care what form the relief comes in. Personally, on the comment of people not using Imitrex the injectable form simply because it is an injectable is not true, at least not for me or any of my family members whip get migraines. The pills don’t work while the injections did, but, after ins, my out of pocket cost for 2pens was $185.00. This, for what was sometimes am abortive for one day, 2 out of a month IF I was lucky enough to have the first injection work. The cost of any forms outside of oral pills is usually too extravagant. BOTOX (which did not work for me) cost me, after a prior authorization from my insurance, $1,400.00 per round out of pocket (still making payments) the copay card will assist with $400 for the first round, and $200 each subsequent round. When it’s time for the ER you’re getting poked anyways, to do so in the comfort of my own home in my nice dark bedroom with blackout curtains and quiet, is something I would absolutely choose over having to go out for treatment.

  • maria.deleon moderator author
    2 years ago

    Hi, everyone…hope that everyone is having a good week..sorry that I have been without WiFi for a few weeks …I have missed being able to I tercer with everyone..in regards to both ann’s and soltería comments I appreciate both of your inputs ..I agree with soltería that when we are in pain we would do anything to find relief. I do have some positive news which I just discovered today..all my research of CGRP had led me to as I said before treatments which were all injectables however, I discovered there is a phase 3 study with an oral dissolvable compound which has enrolled its first patient as of March …rimegepant ( zydis) for acute treatment of migraine..now this if proves effective could be more powerful an drank higher than the other cgrp’s in my opinion…will keep you posted/ Maria deleon / author/ moderator / patient advocate!

  • Ann
    2 years ago

    Your last statement in your post about the new treatment being highly unlikely to eradicate all migraine or improve the life of all migraineurs rang a bell with me. I have no illusions about CGRP antibodies helping me. I am glad that it might be the answer for some sufferers. I’m used to being left out of the mix. Why? It’s because I do not have pain. I have been diagnosed with ocular, abdominal and vestibular migraine. I initially had hormonal migraines each and every month until menopause and then the rest of the symptoms kicked in and the pain retreated. The guess is: It was because of my then diagnosis of an autoimmune disease called hashimotos. Autoimmune is not foreign to me as I suffered from endometriosis throughout my childbearing years. It was also suggested that hashimotos was not diagnosed in my case for many years prior to the antibodies test I was finally administered. The vitiligo, and the other symptoms were always brushed off. Many of you reading this may think I’m lucky that I don’t experience the pain. I did for 41 years and I have to admit being sick to my stomach, running to the bathroom every night, dizzy and blinded by flashing lights is my Achilles heel. I took Anacin for 41 years for the pain and it helped to an extent. There is absolutely nothing I can take now to relieve my symptoms. I have tried everything. I have been everywhere and there is no answer. Doctors can ply me with pills for the diarrhea or for the dizziness (there’s nothing for blindness) but I only suffer from the side effects from these drugs plus it all comes back and I have that plus side effects to contend with. I am not optimistic as I don’t think a cure for migraine neurological disorder will be found in my lifetime. It is not a headache and until that fact is accepted no treatment will ever help us all. However, I agree with your statement that it is an addition to the treatment of a complex disease and for those who achieve some relief, I say I’m happy for you.

  • Soteria
    2 years ago

    Desperate for relief – and willing to grasp at straws – absolutely. All chronic (and even episodic) migraineurs will pretty much do anything to avoid another But having been a part of one of the CGRP studies, I would like share my experience. Migraineur since age 5, migraines kicked in big time at menopause with the added baggage of extreme nausea and horrible brain fog ‘hangover’, sometimes lasting for days. As most sufferers who have been prescribed Immitrex know, there is a limit to the number/amount of medication you can get each month, and you then roll the dice trying to determine if this headache will be intense enough to warrant taking one of the precious meds. And those with heart issues cannot take this med due to the possible heart interaction. (I never once took Immitrex without wondering if there would be possible damage to my heart). And it was always 50/50 whether it would work or not. Preventatives? The zombie-like brain fog from them was unbearable, and I was concerned about what they were doing to my brain chemistry. I tried everything without success, and when I entered the study, I had little hope that it would actually work as nothing else I tried did. I was in the study where the antibody was given by infusion. And I noticed the difference almost immediately. Migraines lessened dramatically in both frequency and intensity and continued improving while I was in the study. Placebo effect? Not a chance. And did they stop completely? No, but they became totally manageable and more a minor part of my life instead of totally controlling it. As I understand it, most of the antibodies target the CGRP peptide with one company’s product targeting the receptors. I am aware that we have these receptors throughout our bodies so the jury is still out as to how this may affect them. But I am planning to be first in line as soon as this becomes available, because for me, the benefits far outweigh the possible risks. Oh yeah… the migraines came back about 6 months out of the study…. I am counting the days until I hear they have FDA approval.

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