Incorporating CGRP Inhibitors Into Clinical Use With AHS Guidance

Kathleen Digre, MD, FAHS

With the 3 most recently approved preventive medicines for migraine now widely available and in use and the anticipated influx of additional treatments in coming years, the American Headache Society (AHS) put out a consensus statement to provide guidance on clinical practice.

The guideline laid out a set of 5 circumstances which must be met in order to use the recently approved CGRP monoclonal antibodies, including erenumab (Aimovig, Amgen/Novartis), fremanezumab (Ajovy, Teva), and galcanezumab (Emglaity, Eli Lilly). Additionally, it included recommendations for situations in which a number of available therapeutics and devices should be utilized.

To further discuss the AHS’s position and its recommendations for migraine treatment, NeurologyLive spoke with sitting AHS President, Kathleen Digre, MD, FAHS, a professor of Neurology and Ophthalmology at the John A. Moran Eye Center, and the Chief of the Division of Headache and Neuro-ophthalmology, as well as an adjunct professor of Obstetrics and Gynecology and adjunct professor of Anesthesia at the University of Utah in Salt Lake City.

The AHS position statement was published in Headache.

NeurologyLive: What was the AHS seeking to achieve with this statement?

Kathleen Digre, MD, FAHS: This statement was made on behalf, really, of our patients because we realize that there are a lot of treatments out there for migraines, and we wanted providers of all types to have some guidelines on how to incorporate new migraine treatments into clinical practice in a practical way. To do that, we talked to lot of stakeholders, we talked to employers, pharmacy benefit people, device manufacturers, pharmaceutical manufacturers, health companies, patients, insurance providers, and then thought leaders in headache—experts in both Canada and the US and even Europe—just to come up with a consensus on how we thought all of this worked together. It was really done with our patients in mind, but with the idea that we wanted to discuss how to incorporate new therapies into what you’re already doing.

What are you anticipating the impact of CGRP inhibitors to be going forward?

These are really the first designer drug preventatives for migraine, if you think about it. They don’t treat other pain problems—they’re designed drugs for migraine. Yes, they’re expensive, but for those who are missing work and need to be on a preventative to keep going and have their life together, this can be a life-changing treatment for them.

If somebody responds to a very inexpensive beta-blocker, tricyclic antidepressants—all drugs that have different indications—great, that’s fine. But for some people, they don’t respond to those medications, or they have adverse effects, or they have compliance problems. There are all kinds of reasons why somebody would not continue those medications or why they aren’t working. This really is the first designer drug for migraine, and for some people, it’s going to be really helpful. There are people that this is not going to work for. I see indications in my practice—there are people responding beautifully and there are people who are not responding hardly at all. It’s not going to be a magic pill or a magic shot, or a magic anything, but it will be helpful.

And it’s not just the drugs that are coming out that should give patient’s hope—it’s also devices that are coming out with different ways of modulating systems to take migraine away. This is an exciting time for migraine with more hope for our patients than, probably, ever before.

Has any progress been made in terms of determining the best way to decide individualized treatment in migraine?

We don’t have it figured out yet. In terms of what is the right thing to use for the right person, we don’t have that figured out either. That would be one of the things we hope would happen at some point in time, but we’re not there yet. Unfortunately, we don’t have Dr. Suess machines that you could put people in and say when this person comes out, here’s what’s going to work for this person. Like in MS, or in any other disease process, when we talk about what is going to work for this individual—we don’t know that.

This consensus statement is a really balanced view, and it talks about all of the medications available—simple ones, more complex ones, expensive ones, inexpensive ones—but what it really does is it also gives the evidence for established efficacy, probably efficacious, etc., for treatments.

Physicians have to use their judgment, and providers have to use their judgment. Not just headache providers, but all providers, have to use judgment in knowing the patients, and their comorbidities. For example, when you’re choosing a preventative and the person has a comorbid condition like hypertension, you’re probably going to pick a beta-blocker or a sodium-channel blocker for that patient because it’s going to treat 2 things instead of 1. Or if somebody has epilepsy, you’re probably going to pick an anticonvulsant for that patient.

People have to use judgment based on what’s in front of them, but I think providers also need to know that there’s more than one way to treat migraines. Both acutely and preventively, there’s more than one way to do it. And when you’re taking care of people with migraine, it’s better to have a great big toolbox than have only 2 or 3 tools. I’m very happy that we have so many options that we can put in here.

Any advice for primary care and family medicine in the treatment of migraine?

There’s great advice in the consensus statement. This is a primary care disorder. It’s more common than asthma and diabetes combined, and because of that it behooves all primary care providers to know about migraine and have at least some idea how to treat it. It’s ubiquitous, and they’re going to have it in their practice. Learning as much as they can about migraine—as much as they learn about asthma and diabetes, they need to know about migraine.

REFERENCE

American Headache Society. The American Headache Society position statement on integrating new migraine treatments into clinical practice. Headache. 2019;59(1):1-18. doi: 10.1111/head.13456.