CGRP antagonists for decreasing migraine frequency: New options, long overdue

Article Figures & Data

TABLE 1

Current calcitonin gene-related peptide (CGRP) antagonists

Drug	Mechanism	Dosing and frequency^a	Most common adverse effects^a	Average wholesale price and Pharmaceutical Assistance Program^a
Erenumab	CGRP receptor antagonist	Migraine: 70 or 140 mg subcutaneously, monthly	Injection site erythema or pain, 5%–6% Constipation, 3%	$690 per month (regardless of dose) If commercial insurance plan does not cover or requires prior authorization, patients are eligible for 12 doses over 24 months with a $5 copay card per month; maximum benefit $2,700 annually
Fremanezumab	CGRP ligand antagonist	Migraine: 225 mg monthly or 675 mg every 3 months subcutaneously	Injection site reaction, 45%	$690 per 225-mg syringe Patients with commercial insurance plan are eligible for 12 months of treatment with a $0 copay card; there is no annual maximum benefit; with electronic coupon, copay is $20
Galcanezumab	CGRP ligand antagonist	Migraine: 240 mg, then 120 mg per month subcutaneously Cluster headache: 300 mg at onset of cluster period, then monthly until end of cluster headache	Injection site reaction, 18%	$690 per 120-mg autoinjector If commercial insurance plan does not cover or requires prior authorization, patients are eligible for a $0 copay card; maximum coverage is $4,900 annually As of 2020, this benefit is available only after prior authorization is approved by insurance
Eptinezumab	CGRP ligand antagonist	100 mg/mL or 300 mg/mL via infusion every 90 days	Nausea, 1.6% Fatigue, 1.4%	$1,495 per infusion ($5,980 per year)

↵a Information from product package inserts and personal communication with Cleveland Clinic Adherence Specialty Pharmacy.

TABLE 2

Efficacy of calcitonin gene-related peptide antagonists in clinical trials of migraine prevention

Authors	Treatment	No. of patients	Baseline migraine days per month	Decrease in migraine days from baseline	50% response rate
Tepper et al²⁶	Erenumab 70 mg monthly	191	17.9	6.6	40%
	Erenumab 140 mg monthly	190	17.8	6.6	41%
	Placebo	286	18.2	4.2	23%

Dodick et al²⁴	Erenumab 70 mg monthly	282	8.1	2.9	40%
Dodick et al²⁴	Placebo	288	8.4	1.8	30%

Reuter et al²⁵	Erenumab 140 mg monthly	121	9.2	1.8	30%
Reuter et al²⁵	Placebo	125	9.3	0.2	14%

Goadsby et al²³	Erenumab 70 mg monthly	317	8.3	3.2	43%
	Erenumab 140 mg monthly	319	8.3	3.7	50%
	Placebo	319	8.2	1.8	27%

Dodick et al²⁷	Fremanezumab 225 mg monthly	290	8.9	4.0	48%
	Fremanezumab 675 mg quarterly	291	9.2	3.0	44%
	Placebo	294	9.1	2.6	28%

Silberstein et al²⁸	Fremanezumab 675 mg, then 225 mg monthly	379	12.8	4.6	41%
	Fremanezumab 675 mg quarterly	376	13.2	4.3	38%
	Placebo	375	13.3	2.5	18%

Stauffer et al²⁹	Galcanezumab 120 mg monthly	213	5.6	4.7	62%
	Galcanezumab 240 mg monthly	212	5.7	4.6	61%
	Placebo	433	5.8	2.8	39%

Skljarevski et al³⁰	Galcanezumab 120 mg monthly	231	9.1	4.1	59%
	Galcanezumab 240 mg monthly	223	9.1	4.2	57%
	Placebo	461	9.2	2.3	36%

Detke et al³¹	Galcanezumab 240 mg, then 120 mg monthly	278	19.2	4.8	28%
	Galcanezumab 240 mg monthly	277	19.4	4.6	28%
	Placebo	558	19.6	2.7	15%

PROMISE-1³²	Eptinezumab 30 mg every 12 weeks	219	8.7	4.0	50.2%
	Eptinezumab 100 mg every 12 weeks	223	8.7	3.9	49.8%
	Eptinezumab 300 mg every 12 weeks	224	8.6	4.3	56.3%
	Placebo	222	8.4	5.4	37.4%

PROMISE-2³³	Eptinezumab 100 mg every 12 weeks	356	16.1	7.7	57.6%
	Eptinezumab 300 mg every 12 weeks	350	16.1	8.2	61.4%
	Placebo	366	16.2	5.6	39.3%