Emerging drugs for the preventive treatment of migraine: a review of CGRP monoclonal antibodies and gepants trials

ABSTRACT

Introduction

Migraine is a leading cause of years lived with disability and preventive strategies represent a mainstay to reduce health-related disability and improve quality of life of migraine patients. Until a few years ago, migraine prevention was based on drugs developed for other clinical indications and relocated in the migraine therapeutic armamentarium, characterized by unfavorable tolerability profiles. The advent of monoclonal antibodies against Calcitonin Gene-Related Peptide (CGRP) and gepants, CGRP receptor antagonists, has been a turning point in migraine prevention owing to advantageous efficacy, safety and tolerability profiles.

Nevertheless, while in an ideal scenario a drug characterized by significant greater efficacy and tolerability compared to existing therapeutic strategies should be adopted as a first-line treatment, cost-effectiveness analyses available for monoclonal antibodies against CGRP pathway tend to limit their administration to more severe migraine phenotypes.

Areas covered

The present narrative review aims to provide a critical appraisal of phase II and III CGRP-mAbs and gepants trials to analyze their use in clinical practice.

Expert opinion

Despite monoclonal antibodies against CGRP pathway and gepants can be undoubtedly considered top-of-the-range treatments, there are still issues deserving to be addressed in the coming years as the risk of off-target effects as well as their economic sustainability based on the considerable migraine burden.

KEYWORDS:

• Atogepant
• CGRP
• eptinezumab erenumab
• fremanezumab
• galcanezumab
• gepant
• monoclonal antibody
• rimegepant

Disclosure of interest

M Silvestro has received speaker honoraria from Novartis, Teva and Lilly.

A Tessitore has received speaker honoraria from Novartis, Schwarz Pharma/UCB, Lundbeck, Abbvie and Glaxo and serves as associate editor of European Journal of Neurology.

G Tedeschi has received speaker honoraria from Sanofi-Aventis, Merck Serono, Bayer Schering Pharma, Novartis, Biogen-Dompé AG, Teva and Lilly; has received funding for travel from Bayer Schering Pharma, Biogen-Dompé AG, Merck Serono, Novartis and Sanofi Aventis; and serves as an associate editor of Neurological Sciences.

A Russo has received speaker honoraria from Allergan, Lilly, Novartis and Teva and serves as an associate editor of Frontiers in Neurology (Headache Medicine and Facial Pain session). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.