In 2018, three
calcitonin gene-related peptide (CGRP) pathway
monoclonal antibodies,
erenumab,
fremanezumab and
galcanezumab, were approved in various parts of the world, including Europe and the US, and another,
eptinezumab, is pending, for the prevention of
migraine. In this article, episodic
migraine treatment is reviewed, although these medicines are approved and are just as effective for chronic
migraine. These new medicines usher a new phase in the preventive management of
migraine with
migraine-specific treatments. Data from phase III trials of CGRP pathway
monoclonal antibodies have shown they are efficacious, with adverse effect rates comparable to placebo. The combination of clear efficacy and excellent tolerability will be welcome in an area where poor adherence to current preventives is common.
Rimegepant,
ubrogepant and
lasmiditan are
migraine-specific acute
therapies yet to be approved by regulators. Phase III data for the respective
CGRP receptor antagonists, the
gepants, and the
serotonin 5-HT1F receptor agonist, the ditan, have been positive and free of cardiovascular adverse effects. These medicines are not
vasoconstrictors. When approved, they could meet the acute
therapy demand of patients with cardiovascular risk factors where
triptans are contraindicated. Beyond this,
gepants will see the most disruptive development in
migraine management in generations with medicines that can have both acute and preventive effects, the latter evidenced by data from the discontinued
drug telcagepant and the early-phase
drug atogepant. Moreover, one can expect no risk of
medication overuse syndromes with
gepants since the more patients take, the less
migraines they have. During the next years, as experience with
monoclonal antibodies grows in clinical practice, we can expect an evolution in
migraine management to take shape. Clinicians will be able to offer treatment patients want rather than trying to fit migraineurs into therapeutic boxes for their management. Despite pessimistic susurrations of a largely addlepated form, many patients, and physicians, will welcome new options, and the challenges of new treatment paradigms, with optimism.