EAN 2022 | For or against? Anti-CGRP monoclonal antibodies as a first-line therapy for migraines

This is really a hot topic because there are those new drugs which are really game changers in migraine prevention because they offer a lot of additional benefits to patients. However, there are also some shortcomings related to those treatment. One of the major shortcomings, while we are discussing if they should or should not be first-line treatment, is the direct cost because the direct cost, it’s much higher than the conventional drugs. So we have to consider several things.

First thing is that so far, we do not have head-to-head studies comparing old drugs with the monoclonal antibodies to address if they are more effective. There’s only one single randomized study comparing a monoclonal antibody with an antiepileptic, but the primary endpoint of this study was not efficacy, but was tolerability. So we do not have enough data to say if they are better, or not better, than conventional drugs.

We have the high direct cost and we have to make treatments also affordable from an economic perspective for the society, because we have to give treatments not only to patient with headache but to all patients. So we have to allocate the most expensive treatments to patients who are more in need of them. If we have a patient with low burden of headache, maybe we can consider as first-line treatment also the conventional drug, because often in those patients, the short course of treatment is sufficient. Also conventional drug can work in this sense. Whereas we can prefer the new drug, the new and most expensive drugs, in those patients who are the more in need of the treatment. They can be represented, for example, by those having a very high frequency of migraine or headache attacks, those of medication overuse, and those who have comorbidities, which preclude the user of the conventional drugs.

It’s important also to point out that considering the peculiar patients’ characteristics. In some patients, the oral drugs, the conventional drugs can be preferred. Let’s think to a patient who has headache together with depression or insomnia. In this case, you can consider that an anti-depressant as first-line. If a patient is obese, you can consider the topiramate first-line.

I think that to finally answer to your question, the right choice is not to consider but them in general as a first or not first-line treatment, but to select the right treatment for each patient.