Migraine
Also known as: CGRP · headache
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Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: An American Headache Society position statement update
American Headache Society (AHS) · 2024 · 2024 update
An American Headache Society position statement update on where CGRP-targeting drugs sit in the migraine prevention pathway. It reviews the accumulated efficacy, tolerability and safety evidence for the four anti-CGRP monoclonal antibodies and two preventive gepants and addresses whether patients must first fail older preventive drug classes. Published in Headache in 2024.
European Headache Federation guideline on the use of monoclonal antibodies targeting the calcitonin gene related peptide pathway for migraine prevention - 2022 update
European Headache Federation (EHF) · 2022 · 2022 update
The European Headache Federation's GRADE-based guideline on prescribing CGRP-pathway monoclonal antibodies for migraine prevention in episodic and chronic migraine. It updates the federation's earlier guidance using newer randomised trials and real-world data, and issues expert-opinion statements where formal evidence grading was not possible. Published in The Journal of Headache and Pain in 2022.
US vs EU key differences
- The two bodies converge on first-line status for CGRP-pathway therapy, but Europe got there first: the EHF stated in its 2022 update that CGRP monoclonal antibodies should be included as a first-line preventive option, and the American Headache Society reached the same position in March 2024. source
- Both statements abandoned an earlier step-therapy gate: the EHF's 2019 guideline had required inadequate response or intolerance to at least two categories of preventives, and the previous AHS consensus required trials of at least two first-line classes for at least eight weeks before CGRP-targeting therapy. source
- The European guideline adds explicit stewardship rules the US position statement does not: efficacy should be judged only after a minimum of three consecutive months of treatment, and a treatment pause should be considered after 12-18 months of continuous use, with restart if migraine worsens on withdrawal. source
- Drug scope differs: the EHF 2022 document covers only the four injectable CGRP-pathway monoclonal antibodies (eptinezumab, erenumab, fremanezumab, galcanezumab), while the AHS 2024 statement covers CGRP-targeting therapies more broadly, including oral small-molecule agents. source
What changed recently
- US2018/2019 position statement → 2024 update2024-03-11
The updated position statement drops the requirement that patients first fail conventional preventives before receiving CGRP-targeting drugs, placing the anti-CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) and the gepants rimegepant and atogepant alongside older agents as first-line migraine prevention.
source ↗curation confidence 90% - EU2019 → 2022 update2022-06-11
The 2022 EHF update promotes anti-CGRP monoclonal antibodies from the third-line position they held in 2019 (after failure of two other preventive classes) to a first-line option, and newly advises pausing treatment after 12-18 continuous months with restart as needed, citing head-to-head data favouring erenumab over topiramate.
source ↗curation confidence 90%
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