Monoclonal Antibodies, Gepants, and Triptans Show Little Differences in Possible Response Predictive Variables

Loretta Mueller, DO, FACOFP

As questions in the migraine community about the comparative differences between the newer targeted treatments and the older mainstay therapies for migraine abound—particularly the need to identify predictors of response—new data suggest that there appear to be no marked differences in terms of neck pain, anxiety, depression, and insomnia, compared with the lack thereof, among patients who have been treated with all three classes of calcitonin gene-related peptide, or CGRP, system medicines assessed.¹

Those therapies included in the study were the monoclonal antibodies, the gepants, and the triptans that had been used by patients at the Jefferson New Jersey Headache Center from May 1, 2020, to December 31, 2020. Notably, individuals in the assessment reported a low overall triptan response rate of 28%, which the authors noted “may be representative of a real-world tertiary headache center population who had tried all three classes of medications and may not be generalizable to other cohorts.”

The data were presented at the 2022 American Headache Society (AHS) Annual Scientific Meeting, June 9-11, in Denver, Colorado, in a poster by Loretta Mueller, DO, FACOFP, headache specialist, Cooper Neurological Institute, Cooper University Health Care. “The primary objective of the study was to evaluate [the] impact of variables neck pain, anxiety, depression, and insomnia on response to triptans, gepants, and monoclonal antibody medications targeting CGRP in migraine patients who had used all three,” Mueller and colleagues wrote.

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“Migraine patients have a variable and often unpredictable response to medications, stepping through a multitude of therapies,” they added, noting that “finding a predictive clinical variable for migraine response would be valuable in many ways including patient quality of life.”

The retrospective electronic chart review included 1080 headache visit electronic health record notes reviewed during the 8-month period, which detailed 92 patients who had used a monoclonal and gepant at some point, and 75 patients who had used a monoclonal antibody, gepant, and triptan at some point, all of whom had evaluable response data. Response was defined by patient notes stating medication helped their condition, and response for each variable was calculated for each medication class.

The majority of those included were women (89.1%) with a diagnosis of chronic migraine (83.7%), aged 18 to 70 years (mean, 32.1). The total percentage of individuals with neck pain was 54.3%, while anxiety was reported by 38%, depression by 32.6%, and insomnia by 39.1%.

For neck pain, compared with the rate for those without neck pain, the responder rate among monoclonal antibody users was 60% vs 64.2%, respectively. Among monoclonal antibody users for anxiety, depression, and insomnia compared with those without, the respective responder rates were 60% vs 63.2%, 66.7% vs 59.8%, and 55.6% vs 66.1%.

Similarly, the gepant responder rate for neck pain was 58% vs 47.6% without neck pain, 60% with anxiety vs 50.8% without anxiety, 63.3% with depression vs 50% without depression, 63.9% with insomnia vs 46.4% without insomnia. The triptan responder rate was 29.7% for those with neck pain vs 26.3% for those without neck pain, was 28% for those with anxiety vs 28% without, was 34.8% for those with depression vs 25% without, and was 24% for those with insomnia vs 30% without insomnia.

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REFERENCE
1. Mueller L, Ciervo S. Are there clinical variables predictive of gepant, CGRP monoclonal antibody, or triptan response in migraineurs? Presented at: AHS Annual Scientific Meeting; June 9-11, 2022; Denver, CO. P-153.