Extreme ecchymoses in a migraine patient using concomitant treatment with calcitonin gene-related peptide receptor antibodies and fish oil supplements: a case report

Abstract

Background Erenumab, a monoclonal antibody against the calcitonin gene-related peptide (CGRP) receptor, is registered for migraine prevention. Compared to other conventional migraine prevention medicines (i.e. topiramate, betablockers and amitriptyline) erenumab has better tolerability. Impaired hemostasis has not been reported previously. Here, we report the first case of an increased tendency to bruise in a migraine patient treated with erenumab. Case presentation A 41-year old female migraine patient was treated with erenumab for 12 months, which led to a significant reduction of headache and migraine days. Three months after treatment start, she experienced increased tendency to bruise leading to extreme ecchymosis after 4 months treatment. Platelet counts and aggregation, thromboelastography, activated partial thromboplastin time (APTT) and international normalized ratio (INR) were all normal. Thorough interview revealed intake of fish oil supplements for many years prior to treatment. The increased tendency to bruise subsided after discontinuation of fish oil supplements. Conclusion The combination of fish oil supplements and erenumab may cause increased tendency to bruise. Erenumab has no effect on the platelets per se but may cause impaired wound healing by suppression of CGRP. Thus, small and unnoticeable bruises may be aggravated instead in patients with tendency to bruise caused by for instance fish oil supplements.

The neuroimmune CGRP-RAMP1 axis tunes cutaneous adaptive immunity to the microbiota

“…Direct perturbations of systemic CGRP activity such as migraine treatment or prevention (Deen et al 2017;Russo and Hay 2023) may also be able to impact commensal-specific lymphocytes at the barrier tissue, potentially contributing to side effects over the course of this powerful migraine therapeutic or prophylactic approach. Intriguingly, many side effects from migraine management that have been documented, such as exacerbated inflammation (Tracey 2002), altered course of wound healing or bruising (Wurthmann et al 2020;Cullum et al 2021) and alopecia (Ruiz et al 2023), involved dysregulation at barrier tissues, raising an intriguing possibility that intervention with the CGRP-RAMP1 axis may have broader consequences at barrier sites in the clinical or human health context. With the emergence of acute migraine treatment approaches such as intranasal sprays (Reuter 2023), where CGRP modulatory molecules are directly deposited at barrier tissues such as the nasal mucosa, the uncharacterized impact of CGRP on local tissue physiology, whether adverse or beneficial to human health, warrants further studies.…”