Effectiveness of dual migraine therapy with CGRP inhibitors and onabotulinumtoxinA injections: case series

Toni, Tahlia; Tamanaha, Rayce; Newman, Bashak; Liang, Yutong; Lee, James; Carrazana, Enrique; Vajjala, Vimala; Viereck, Jason; Liow, Kore

doi:10.1007/s10072-021-05547-x

Cited by 15 publications

(16 citation statements)

References 6 publications

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“…Even if the advent of monoclonal antibodies acting on the CGRP pathway has revolutionized the therapeutic expectancies of those patients, their migraine burden may remain high [ 26 ]. Clinical practice suggests that combined treatments with oral drugs and/or non-pharmacological interventions could provide a further substantial benefit to patients with suboptimal treatment with monoclonal antibodies; however, there are no available data on the efficacy of add-ons to monoclonal antibodies, except from observational studies of combination with onabotulinumtoxinA [ 27 – 31 ]. An algorithm for the use of onabotulinumtoxinA for chronic migraine already proposed combination with oral agents in patients with partial response to the injective treatment [ 32 ]; the same can apply to erenumab and other monoclonal antibodies.…”

Section: Discussionmentioning

confidence: 99%

Comparing the relative and absolute effect of erenumab: is a 50% response enough? Results from the ESTEEMen study

et al. 2022

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Background Monoclonal antibodies acting on the calcitonin gene-related peptide (CGRP) or its receptor have changed migraine preventive treatment. Those treatments have led to reconsidering the outcomes of migraine prevention. Available data mostly considered benefits in terms of relative efficacy (percent or absolute decrease in monthly migraine days [MMDs] or headache days compared with baseline). However, not enough attention has been paid to residual MMDs and/or migraine-related disability in treated patients. In the present study, we aimed at comparing the relative and absolute efficacy of erenumab. Methods ESTEEMen was a collaborative project among 16 European headache centers which already performed real-life data collections on patients treated with erenumab for at least 12 weeks. For the present study, we performed a subgroup analysis on patients with complete data on MMDs at baseline and at weeks 9-12 of treatment. Starting from efficacy thresholds proposed by previous literature, we classified patients into 0-29%, 30-49%, 50-74%, and ≥75% responders according to MMD decrease from baseline to weeks 9-12 of treatment. For each response category, we reported the median MMDs and Headache Impact test-6 (HIT-6) scores at baseline and at weeks 9-12. We categorized the number of residual MMDs at weeks 9-12 as follows: 0-3, 4-7, 8-14, ≥15. We classified HIT-6 score into four categories: ≤49, 50-55, 56-59, and ≥60. To keep in line with the original scope of the ESTEEMen study, calculations were performed in men and women. Results Out of 1215 patients, at weeks 9-12, 381 (31.4%) had a 0-29% response, 186 (15.3%) a 30-49% response, 396 (32.6%) a 50-74% response, and 252 (20.7%) a ≥75% response; 246 patients (20.2%) had 0-3 residual MMDs, 443 (36.5%) had 4-7 MMDs, 299 (24.6%) had 8-14 MMDs, and 227 (18.7%) had ≥15 MMDs. Among patients with 50-74% response, 246 (62.1%) had 4-7 and 94 (23.7%) 8-14 residual MMDs, while among patients with ≥75% response 187 (74.2%) had 0-3 and 65 (25.8%) had 4-7 residual MMDs. Conclusions The present study shows that even patients with good relative response to erenumab may have a clinically non-negligible residual migraine burden. Relative measures of efficacy cannot be enough to thoroughly consider the efficacy of migraine prevention.

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Section: Discussionmentioning

confidence: 99%

Comparing the relative and absolute effect of erenumab: is a 50% response enough? Results from the ESTEEMen study

et al. 2022

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“…A recent consensus suggests the combination of onabotulinumtoxinA with anti-CGRP mAbs as a possible therapeutic strategy in patients with refractory migraine or a suboptimal response to the single treatment. 94 Some case series proved the efficacy of this combined treatment in reducing MHDs/MMDs 95 , 96 and headache severity 97 with no safety concerns thanks to the optimal tolerability and safety profiles of the treatments. 95–98 Both the treatments act on the CGRP pathway: mAbs inhibit CGRP binding to its receptor on Aδ-fibers, onabotulinumtoxinA exerts its action on C-type fiber with still unknown mechanisms; thus, their concomitant use might enhance the blockade of the pathway.…”

Section: Future Treatment Perspectivesmentioning

confidence: 92%

Migraine Prevention with Erenumab: Focus on Patient Selection, Perspectives and Outcomes

Sacco¹,

Ornello²

2022

TCRM

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Erenumab is a monoclonal antibody targeting the calcitonin gene-related peptide (CGRP) receptor suitable for episodic and chronic migraine prevention. Randomized clinical trials proved the superiority of erenumab to placebo in a strictly selected population, while real-world studies confirmed treatment efficacy in more severe forms of disease – most patients suffered from chronic migraine with medication overuse headache, had prior treatment failures, and long disease duration. According to guidelines, anti-CGRP pathway monoclonal antibodies should be reserved to patients who failed or have contraindication to several classes of preventive treatments. However, their ease of use, tolerability and efficacy make these monoclonal antibodies ideally suitable for most patients with migraine; cost-effectiveness needs to be considered when looking at expanding current prescription criteria. Also, data from open label extensions of randomized control trials confirmed sustained benefits of prolonged treatment up to 5 consecutive years without significant risk of adverse events. Further studies will provide insights on optimal treatment duration to achieve migraine remission and predictors of treatment response. In the present work, we aimed at reviewing design and results of the main studies on erenumab and discussing treatment use in the current migraine prevention scenario; we also summarized the main ongoing research projects and provided clinical perspectives for the future.

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“…All groups experienced an improvement in the number of headache-free days (P=0.007), with the greatest improvement seen in the fremanezumab group (mean improvement of 12.6 headache-free days). The erenumab group experienced a mean improvement in headache-free days of 6.4, and the smallest improvement was seen in the galcanezumab group (3.8 headache-free days) 6869. Most CGRP antagonists have not been studied in patients with cardiovascular disease and should therefore be used with caution in patients with these comorbidities.…”

Section: Treatment Of Chronic Migrainementioning

confidence: 99%

Management of chronic migraine

Hovaguimian

Roth

2022

BMJ

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Chronic migraine is a neurologic disorder associated with considerable disability, lost productivity, and a profound economic burden worldwide. The past five years have seen a dramatic expansion in new treatments for this often challenging condition, among them calcitonin gene related peptide antagonists and neuromodulatory devices. This review outlines the epidemiology of and diagnostic criteria and risk factors for chronic migraine. It discusses evidence based drug and non-drug treatments, their advantages and disadvantages, and the principles of patient centered care for adults with chronic migraine, with attention to differential diagnosis and comorbidities, clinical reasoning, initiation and monitoring, cost, and availability. It discusses the international guidelines on drug treatment for chronic migraine and evaluates non-drug treatments including behavioral and complementary therapies and lifestyle modifications. Finally, it discusses the management of chronic migraine in special populations, including pediatrics, pregnancy, and older people, and considers future questions and emerging research in the field.

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Effectiveness of dual migraine therapy with CGRP inhibitors and onabotulinumtoxinA injections: case series

Cited by 15 publications

References 6 publications

Comparing the relative and absolute effect of erenumab: is a 50% response enough? Results from the ESTEEMen study

Comparing the relative and absolute effect of erenumab: is a 50% response enough? Results from the ESTEEMen study

Migraine Prevention with Erenumab: Focus on Patient Selection, Perspectives and Outcomes

Management of chronic migraine

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