What is CGRP?
Calcitonin gene-related peptide (CGRP) is known to be closely involved in the cascade of events that lead to a migraine attack. Recently, positive results have arisen from Phase 2 clinical research studies showing that CGRP antibodies for migraine may offer an entirely new approach in the treatment and prevention of migraine.
Most treatments for migraine were originally designed for other conditions such as epilepsy, hypertension or depression. This class of CGRP treatments are exciting as they are the first preventative treatment designed specifically for migraine.
To understand CGRP we need to understand a few terms. These are:
- Amino acids
- Trigeminal nerve
Amino acids are essentially the building blocks of proteins in our body. They are responsible for the transport and storage nutrients.
A peptide is a type of amino acid.
It is a naturally occurring biological molecule found in every cell and tissue. It performs a wide range of functions in the body including the regulation of hormones.
The difference between a peptide and a protein is the number of amino acids it contains. Generally speaking when a molecule contains 2-50 amino acids it is considered a peptide. If there are more than 50 amino acids it’s classified as a protein. (1)
CGRP stands for calcitonin gene-related peptide (CGRP). CGRP is known to be involved at the molecular level in the migraine process. It is also one of the strongest vasodilators in our body.
Contrary to popular opinion, vasodilatation is not believed to cause migraine pain.
Our brain does not have the ability to feel pain. Instead, the trigeminal nerve passes the sensation of pain on the brain’s behalf. The trigeminal nerves are the nerves around the head which are responsible for sensations in the face, head and motor functions such as chewing.
During a migraine headache, CGRP is released and binds to receptors in the trigeminal nerve which leads to pain. (2)
CGRP levels have been shown to be elevated during a migraine attack. (9)
How does the CGRP treatment work?
Today most experts believe that migraine is a neurological disorder that begins inside the brain, occurring primarily in the brainstem with the activation of certain brain structures.
These same brain structures cause peptides including CGRP, to be released.
CGRP then binds to receptors which leads to vasodilation and muscle relaxation which leads to inflammation and pain.
The released peptides bind to specific receptors which cause sensitization. (2) Ordinary stimuli such as light, sound and smell can then cause pain.
The secret of this latest generation of CGRP treatment is inhibiting CGRP through use of monoclonal antibodies.
A monoclonal antibody is a protein that is used by the immune system to identify and neutralize harmful agents such as bacteria and viruses.
Monoclonal antibodies are designed to bind to a specific substance. They can detect or purify that substance.
CGRP monoclonal antibodies bind to CGRP to prevent the activation and sensitization of trigeminal nerves.
CGRP monoclonal antibodies prevent migraine by:
- binding with the CGRP released from trigeminal sensory nerve fibers
- preventing activation of trigeminal nerves
- preventing CGRP induced activation of sensitized central trigeminal pathways
- preventing attacks in migraine susceptible individuals
Research to date
In the 1990s, CGRP was discovered by one of the most effective treatment classes currently available, the triptans. Common triptans include Sumatriptan (Imitrex, Imigran), Rizatriptan (Maxalt), Zolmitriptan (Zomig) etc.
During studies to understand what role the triptans performed in preventing the migraine it was discovered that CGRP was inhibited by the triptans. Triptans cause vasoconstriction.
The early studies showed that if you inhibit CGRP you could do what the triptans are doing but without causing vasoconstriction.
The aim was to block CGRP without causing the vasoconstriction that the triptans caused. (2)
Interestingly, tests showed that if CGRP is injected via IV it delivered a migraine attack in migraine patients. (3)
Researchers wanted to know if the reverse was true.
If they blocked CGRP, could they block migraine? In medical terms this is called an antagonist. An antagonist is something which interferes with or inhibits the physiological action of something else.
Early results showed that it did indeed work. In fact, it delivered the same efficacy or effectiveness as the triptans in the use of acute migraine treatment. (4)
Telcagepant was one of the key drugs developed in these initial trials. However it was associated with serious liver toxicity side effects. Therefore treatment with Telcagepant was stopped.
This is where the monoclonal antibodies began.
The monoclonal antibodies specifically targeted CGRP. This development also shifted the focus of CGRP treatment from acute treatment of a migraine attack to a preventative solution. For monoclonal antibodies to be effective they would need to be regularly topped up.
There are 4 monoclonal antibodies either available or in development. Three target CGRP itself whilst one antibody targets the receptor (AMG 334).
There is a functional difference between a CGRP antagonist which targets the receptors versus one which targets the CGRP itself.
When the receptor is targeted it causes a complete lockout. All CGRP signaling is blocked.
The 3 antibodies which are targeting the CGRP itself, allow for some CGRP signaling during therapy. This avoids the potential effects of a long-term total disruption to the normal physiological functions of the CGRP system which are currently unknown.
Which approach is best? We don’t know. A complete lock might be better for your immediate migraine attacks but it could do long term damage as it is a more aggressive intervention. Only time will tell as more comprehensive, long term studies are conducted.
The companies and drug names involved in the research are:
- Teva Pharmaceutical Industries (Fremanezumab TEV-48125) now marketed with brand name Ajovy.
- Eli Lilly and Company (Galcanezumab LY2951742) now marketed with brand name Emgality.
- Alder Biopharmaceuticals (Eptinezumab ALD403) not yet available as at January, 2019.
- Amgen (Erenumab AMG 334) now marketed with brand name Aimovig.
The below chart shows the summarized results from published phase II clinical trials of the anti-CGRP antibodies.
Fremanezumab from Teva found that 53% of patients reduced the frequency of their days with migraine by 50% or more. Those given the placebo experienced a 28% reduction. Teva also looked at a subgroup of patients who reduced their days with migraine by 75% or more. 33% patients experienced a reduction of 75% days with migraine whilst 11% on placebo also experienced the same result. (10)
Galcanezumab from Lilly found that 70% of patients reduced the frequency of their days with migraine by 50% or more. Those given the placebo experienced at 45% reduction. Lilly also looked at a subgroup of patients who reduced their days with migraine by 75% or more. 49% patients experienced a reduction of 75% days with migraine whilst 27% on placebo also experienced the same result. Lilly also had a subgroup of patients who experienced a complete remission with 100% of days measured free from migraine during the trial period. 32% of patients experienced freedom from migraine whilst 17% on placebo also experienced no days with migraine. (5)
Eptinezumab from Alder found that 61% of patients reduced the frequency of their days with migraine by 50% or more. Those given the placebo experienced at a 33% reduction. Alder also looked at a subgroup of patients who reduced their days with migraine by 75% or more. 33% of patients experienced a reduction of 75% days with migraine whilst 9% on placebo also experienced the same result. Lilly also had a subgroup of patients who experienced a complete remission with 100% of days measured free from migraine during the trial period. 16% of patients experienced freedom from migraine whilst 0% on placebo experienced no days with migraine. (6)
Erenumab from Amgen (Aimovig) found that 46% of patients reduced the frequency of their days with migraine by 50% or more. Those given the placebo experienced a 30% reduction. (11)
Why is the placebo effect so strong?
Researchers suspect placebo was high in these due to heightened expectations, bi-weekly clinic visits and administration via injection.
Side effects are minimal
Fortunately the new generation of CGRP monoclonal antibodies showed no findings of liver toxicity, cardiovascular or adverse events in the studies. (5) So far in research reports, side effects appear to very low.
Minor skin redness, pain or irritation can occur around the injection site but was not common or significant.
As at Jan 7, 2019:
- Aimovig (Amgen), Ajovy (Teva), Emgality (Lilly) have been approved.
- Alder is in Phase 3 Clinical Trials.
Aimovig is available in US pharmacies with a prescription. Patients can self-administer Aimovig 70mg or 140mg once a month via a SureClick autoinjector. Aimovig will cost $575 for once-monthly or $6,900 annually. Co-Pay is available as well as a free 2 month trial for eligible patients at the time of writing at www.aimovig.com
Ajovy will be available within USA pharmacies within two weeks with a prescription. It is available to patients as either a quarterly (675 mg) or monthly (225mg) prefilled syringe dose that can be administered at home or at a doctor’s office. Some insured patients may be able to pay as little as $0 on prescription until their offer expires. More information is available at www.ajovy.com
Emgality is available as a once-monthly self-administered injection. To commence, a loading dose is administered with 120 mg followed by another dose of 120 mg for a total of 240 mg initially. Doses are continued with one 120 mg injection each month thereafter. The treatment will be $6,900 USD a year or $575 a month which is the same as Aimovig and Ajovy. The manufacturer, Lilly, said it will offer the drug at no cost for a year to patients with commercial insurance coverage.
Alder is not expected to become available until 2020.
Fortunately, even after the launch of the CGRP antibodies, trials are still expected to continue to evaluate all the usage, marketing, and safety data. To see if you’re eligible to participate in the current studies being held visit www.clinicaltrials.gov and search for “Migraine CGRP”.
This is the first preventative treatment designed specifically for migraine patients which is very exciting. The positive results of the studies should give hope to many. There are however a few important things to note:
- It’s going to be expensive: Dr. Peter Goadsby, one of the researchers on the projects has already been quoted saying that this will not be a cheap treatment. Monoclonal antibodies are the same type of treatment used in cancer and can be very expensive. Monthly injections in a clinic may also come with a cost.
- They are delivered by injection. Which doesn’t suit many people and is not the easiest format to administer.
- They are strong. The half life of ALD403, for example, is 31 days. That means after 31 days after you’ve taken the treatment, 50% of the drug is still circulating and taking effect in your system.
- This is not a final cure. Phase 2 clinical trials show between 50-70% of patients experiencing a 50% or greater reduction in migraine days. It’s not a cure and acute treatments will still be required for many.
Overall, the fact that we are getting the first wave of treatments specifically for migraine has many people rightly excited.
For the medical community, migraine has traditionally been the black sheep of the family with historically little progress or promise in the field. Now, that’s changing. With more progress comes further research, funding, and publicity which is sorely needed.
Most importantly are these strides towards better care and treatment for all of us out there suffering. If you’re struggling at the moment hold on, there is more hope than ever for a better future.
What to do in the meantime?
Patients are encouraged to find the right doctor. (7)
There are over 14 million people with migraine who meet the criteria for preventative treatment. That’s 40% of the of the total migraine population in the US (37 million). (8)
However only 13% or 4.7 million people are taking preventatives. (8) The side effects of older medicinal preventatives are common and hard tolerate. There are many alternative preventative treatments like Botox and devices such as the Cefaly TENS unit (both FDA approved treatments for chronic migraine) and a variety of complementary therapies and natural treatments which have been shown to benefit those with migraine.
Ultimately you’ll need to find what works for you in partnership with your doctor.
Are you happy with your current migraine treatment or looking for something new? Let me know in the comments below.
- ‘What Are Peptides’ Zealand Pharma. Archived from the original on 6 Apr 2014.
- Bigal, M. Burstein R. et.al. Targeting Calcitonin Gene-Related Peptide (CGRP) for Prevention of Migraine. Webinar. 12 Feb 2015.
- Hasen, JM. Hauge, AW. et.al. ‘Calcitonin gene-related peptide triggers migraine-like attacks in patients with migraine with aura’. Cephalalgia 2010 Oct;30(10):1179-86. doi: 10.1177/0333102410368444.
- Connor KM, Shapiro RE, Diener H-C, et al. Randomized, controlled trial of telcagepant for the acute treatment of migraine. Neurology. 2009;73(12):970-977. doi:10.1212/WNL.0b013e3181b87942.
- Dodick, David W et al. ‘Safety and efficacy of LY2951742, a monoclonal antibody to calcitonin gene-related peptide, for the prevention of migraine: a phase 2, randomised, double-blind, placebo-controlled study.’ The Lancet Neurology , Volume 13 , Issue 9 , 885 – 892
- Dodick, David W et al. ‘Safety and efficacy of ALD403, an antibody to calcitonin gene-related peptide, for the prevention of frequent episodic migraine: a randomised, double-blind, placebo-controlled, exploratory phase 2 trial’ The Lancet Neurology , Volume 13 , Issue 11 , 1100 – 1107
- Dumas, PK. ‘Free at last? New CGRP Drugs To Prevent Migraine Attacks For Most’. MigraineAgain.com June 23, 2015
- Lipton, R.B., Bigal, M.E., Diamond M., et. Al. (2007), Migraine prevalence, disease burden, and the need for preventive therapy, Neurology, 68:343-349, doi: 10.1212/01.wnl.000025280897649.21
- Goadsby, P. J., L. Edvinsson, and R. Ekman. “Vasoactive peptide release in the extracerebral circulation of humans during migraine headache.” Annals of neurology 28.2 (1990): 183-187.
- Sun, Hong, et al. “Safety and efficacy of AMG 334 for prevention of episodic migraine: a randomised, double-blind, placebo-controlled, phase 2 trial.” The Lancet Neurology 15.4 (2016): 382-390.
- Bigal, Marcelo E., et al. “Safety, tolerability, and efficacy of TEV-48125 for preventive treatment of high-frequency episodic migraine: a multicentre, randomised, double-blind, placebo-controlled, phase 2b study.” The Lancet Neurology14.11 (2015): 1081-1090.
Thanks for informing me of what exactly I am taking as a study participant. Migraines less. Also , I seem to be thinking a little clearer. Problem, I feel tired and like about to come down with a cold or flu, everyday. Also, my face has a very very light case of hives. I don’t know if I will continue to participate in the study. I get about 1-2 headaches a week and that sucks but at least the other days I feel fine. I’m really trying. Maybe my body will get use to the antibodies . I hope that when I stop the injections, migraines do NOT come back WORSE.
Hi Olivia, I’m glad to hear it’s working for you. What an interesting opportunity for you. I would hope the DR’s running the study can advise on whether it’s best to continue or not based on your symptoms.
At the end of the day it’s up to you to decide if the symptoms are worth the benefit of fewer migraines… Hope things work out!
I’ve noticed since being in this study my immune system seems to be down and I’m getting one respiratory infection after another. Hmmm
Thank you for this clear and helpful description! I am in one of these trials. I passed the first six month mark where I thought (or hoped) I was getting the placebo as I saw no changes in frequency severity or duration of my migraines. I got the first definite injection of medication three weeks ago and so far no changes. But I’ve read from the first phase results that most experienced relief after 12 weeks so still hoping. At any rate, I appreciate this information; it’s easier to understand than anything else I have read on the topic.
Thank you Ellen! That’s a big compliment 🙂
Hi Carl, Thank you for writing this I agree with Ellen this is certainly the best and clearest information on the web about CGRP treatment for patients. I currently have the chance to take part in a study of LY2951742 and while think this treatment looks hopeful in terms of reducing migraine attacks I do have concerns about the unknown negative side effects of blocking CGRP.
I’m not an expert but while CGRP does have a role in pain and inflammation it also seems to be important in things like maintaining bone density and tissue repair thoughout the body. I am worried that the price I might pay for less migraine pain is thinning bones, poor collagen formation, impaired lung and cardiovascular repair. I can’t seem to find any clear answers on the potential positive effects of CGRP in the body that could be affected by this treatment and I suppose that is probably because it is still unknown at this point. Perhaps the treatments that do not block the receptors are more targeted and won’t effect tissue repair etc.
If you do have any information on this I’d be very grateful for it. Once again thank you so much for this great article.
I have noticed and am aware that women suffer more than men with migraines. This is evident by the few comments below. I have a family history of migraine and am a male. Treatments have varied for me, Sumatriptan works, however I have to get an exception letter to receive 20 tablets a month verses the 7 or 8 that the insurance allows. I usually wait until I have full blown pain to make sure it is truly a migraine before taking one of those precious pills. I average 15 to 20 headaches a month. I have also been on a migraine inhibitor, Depakote (sp?).
My neurologist , well, doesn’t seem to offer much and I don’t know where to turn. Can you help? Thank you.
I also take Sumatriptan 100mg for my migraines. Try Health Warehouse for great prices on this. I get 27 pills for $33.33. That is my cash price, since my insurance stinks.
Sir, my name is Bruce Brooks and I match your number of migraines per month so I was wondering if you have had any success with your treatment lately. The VA does allow me just enough pills to get thru but I break them in half sometimes to make them last. They are 50mg Imitrex. I am scheduled to see a neurologist for the first time in coming weeks and I have no preventatives that work. They tried Tropomax but my body did not react well to them so back to square one. Any info would be appreciated to firstname.lastname@example.org
Hi, Bruce! I always ask for 100 mg sumatriptan so I can halve them, take the 50 mg that works for me, and pay for fewer refills. I could not tolerate topiramate or other preventives, but sumatriptan has always worked for me.
This is a good tip I use with some preventatives but overuse can occur with acute treatments from the number of days we take it each week/month rather than the specific dose each time. That is important to remember.
I think it’s important for people to know that medication overuse headaches do not happen for everyone. Whenever the subject came up at a doctors appointment, I was sure ro tell them that that couldn’t be the case with me because I was having 5 days to a week each month with no migraines.
It is true that people do have different thresholds… but medication overuse symptoms will likely occur in most people given enough time and strength of doses.
There are many more preventatives available than Topiramate (Topamax) as well as things we can do ourselves to help self mange this disease.
See my note to Gary above Bruce.
The answer is prevention. Sumatriptan can lead to daily migraine attacks if it is overused for 3 months or more.
Therefore the focus needs to be on preventative strategies, treatments and lifestyle changes (good sleep, diet, regular exercise etc) to minimise the frequency of attacks.
There are also some natural treatments that can assist with an acute attack like ginger and ice applications.
The real focus needs to go into prevention Gary. I hope that helps.
For folks that the preventatives dont work for: you may need more than i drug. I take 3 drugs every day to prevent migraines. Efforts on my part to eliminate any of them has proven to me I need all three. I have had no problems with my doc about continuing all three. I had migraines before there were any preventative drugs. First drug was a calcium channel blocker, aka blood pressure med. Then added depakote when it became available. Then added effexor for depression and that really stopped the remaining migraines. No doubt retiring from work and menopause also helped. But I still need all 3 drugs. Tried to topamax in place of the depakote but it made me extremely forgetful so I went back to the depakote.
Thank you for sharing Peg, this is a helpful consideration for others who have only had some success with any one preventative.
My neurologist is very nice. But I know my migraine problem is boring, and she has lots of other, really scary neurological problems to deal with in her practice. Especially as I have not really responded well to the many treatments she’s encouraged me to try.
I heard doctors say that migraine is fascinating. Personally I don’t find them boring and nor should our doctors in my opinion.
Might be time for a fresh perspective Louise? Perhaps something who has a special interest of speciality in migraine?
I am winding down in the open label phase of the Teva CGRP clinical trial. The first 3 months I didn’t know if I was getting drug or placebo. I had 1 or 2 migraines during those 3 months which was remarkable. Then I entered the open label phase which lasts 1 year. I was definitely getting drug. I didn’t know if I was getting high or low dose of the drug. The migraines got progressively worse over time. I was very disappointed. I did not have any side effects at all so I continued with the study to help Teva get my safety data. Once I have completed the study I am going to investigate CBD oil and MMJ when the dispensaries open. The studies are so promising with little to no side effects which is also remarkable because every preventive I’ve taken had hideous side effects. I hope this is the beginning of many more innovative medications to prevent migraine
The good news is that this is only the beginning. There is much more on the way from different approaches and entirely different designs such as neuromodulation. It is an exciting time.
Sorry to hear the trial wasn’t successful. I suspect if one type of CGRP treatment doesn’t work for, it doesn’t rule out the others which are coming… some of them work in very different ways to each other so there is still reason for hope.
I have chronic daily migraines. I noticed that all of the clinical trials for CGRP, used people with between 4-14 migraines a month. Will they be using chronic patients in the future for some of these trials? I am still looking for something that will help me get through even one day a month without a migraine. I don’t remember what that feels like, anymore.
Yes excellent point Mary. Research was conducted separately for episodic migraine vs chronic migraine. I’ve seen results at a headache conference that demonstrates very similar results even for patients with chronic migraine which is very encouraging! It is expected that these CGRP treatments will also be used for chronic migraine patients.
I’m in the same boat! I very rarely get through a week without at least half of it being taken up with pain. I do sympathise and hope there is help eventually for the seemingly growing numbers of people like us across the world.
Keep tabs on the release of these treatments, they hold great promise for people with chronic migraine.
I was in the phase 2 trial for ALS403 and it was the best drug I have ever had! I was very lucky in that about 90% of my migraines and headaches went away for 8 months! I was getting on average 15-19 migraine days per month with a headache every other day for the last 20+ years.. I honestly don’t care how much this drug will be, I will be the first in line to get it! It is a literal life changer!!!
I will be recommending it to every person I know who gets migraines!!
Fantastic results Jenna! Very exciting. I hope you get access to it as soon as possible!
Wow…. this is really exciting news for people like myself who suffer from refractory migraine. After suffering for 18 years and having tried every conceivable treatment some of which have been prescribed by very highly respected physicians I would welcome more information on the trials of CGRP. As a Triptan user who also suffers from trigeminal neuralgia this new treatment sounds wonderful.
Living in hope
There is a lot of hope Martin. Studies have shown that these treatments are effective even if you failed with several other promising treatments.
I am not happy with my migraine treatment. I live in Michigan. Where can I find a good migraine / headache specialist. I do not respond to preventative s or most medications.
The National Headache Foundation has a directory which might provide some options via a postcode search. Visit http://www.headaches.org/physician-finder/
Diahn, my son is a patient at MHNI, Michigan Headache & Neurological Institute in Ann Arbor, MI. They are Migraine Specialists and are very good. You can contact them for a new patient appointment through their website, https://www.mhni.com/
Best of luck to you.
Pauline, thank you for your suggestion to Diahn!
This is a great article with just enough technical info to give us the pros and cons of CGRP. I average 15 to 20 days of migraine per month and use a lot of triptans. I’m anxious to see what’s gonna happen with all this. Thank you for your help.
This should be a promising option. It has been shown in studies and presentations I’ve seen first hand how this helps those who might be overusing current medications or who have failed prior preventative treatments.
I am always looking for something new! After 9+ years of chronic post-craniotomy headaches (now diagnosed as chronic migraine and occipital neuralgia, I use topamax and Effexor as preventatives. I do anRFA on C2,3 and 4 annually to help manage the occipital pain for a good portion of the year and my acute medication is Indocin. None of the triptans or other common migraine therapies have worked for me (and believe me I have tried them ALL in the past 9 years!) Every drug, natural supplement, acupuncture, neurobiofeedback, chiropractors, nerve blocks, in-patient hospital stays at both MHNI and UCSF…and still I wait.
Hopefully this will be worth your wait Barabara! Take care in the meantime.
I just got into phase 2 study for Rimegepant, developed by biohaven pharmaceuticals. From what I understand, It’s a CGRP receptor blocker. I’ll be taking it as an abortive pill, like I’d take a triptan. I’ll also be maintaining a daily electronic diary and have regular check-ups and testing done at a local lab. This is my first clinical trial, and after wrestling with migraine for 20 years, I’m excited to be doing something positive. Even if the drug is ineffective for me, I’m doing something to advance migraine research. It’s a step forward!
Congratulations Judy! Good luck with the trial and keep us in the loop with how it all goes 🙂
I have been suffering from migraine from the age of 25. I’m now 54 and the migraines have steadily become worse and most days I have head pain. I’ve been to a few different neurologists over the years but haven’t found one who was really interested. None of the prophylactic treatments have worked. I take Naratryptan or Rizatryptan for acute attacks. Recently I went "cold turkey" on the tryptans as I suspected I was getting rebound headaches. I forced myself to have no tryptans for 3 weeks. Perhaps I have a few less headaches now but still about 4 days per week. Dies anyone know a neurologist with a special interest in migraine? I live near the Gold Coast in QLD Australia.
Hey Sally, sorry to hear about the progression of migraine over the years. Try contacting Headache Australia or the Australian & New Zealand Headache Society for some potential headache specialists near you. You might need to leave a message if their offices are still closed during the holidays. Good luck!
Where is the information regarding chronic cluster headaches???
I don’t get migraines, only clusters. I am 35 and have been getting them since 5th grade. They have only gotten severely worse in the last 10-12 years. Can’t remember ever having a headache or migraine. Just clusters and they are beyond the worst
Hi Matthew, apologies, I’m not an expert on cluster headache and this guide was written for the migraine audience in mind. What I do know about cluster headache, the ‘suicide headache’ is that the pain is indescribable.
I’d refer to clusterbusters or OUCH UK for more information about cluster headache and what potential for cluster headache CGRP has. I think there is some good news too for cluster patients.
I have chronic migraines that originate with tension on the right side of my neck, then moves to pain over my right eye. 99% of the time the pain will remit with Maxalt. Does this sound like I am a good candidate for CGRP?
It’s too early to tell.
Unofficially I suspect if you respond well to a triptan (which it seems you do with Maxalt) then you might expect good results from the CGRP treatments.
Thank you for all the information. I was diagnosed with 11 types of migraines in 2003. I tried all 48 medications with the neurologist and nothing helped. The last visit I had with him he told me there was nothing else he could do and that I should just find a drug dealer to help with pain. I never do go searching for a drug dealer even though I live with a pounding headache 24/7. My primary doctor put me on a preventative last year and but I haven’t seen any improvement. I had a lot of Botox and 2 nerve blocks a few months ago and they did not work either. I struggle every morning to get out of bed and go to work. I am scared that what if one day I decide I am just completely done with living in pain every single day.
Regan there are pain specialists and headache specialists that can be far more experienced an helpful than the average neurologist. There are a quite a few medicinal and non-medicinal preventative options, strategies and approaches for chronic migraine. It starts with self education and working in partnership with a doctor who is genuinely interested. Doesn’t sound like that with your neurologist. Time for another opinion.
Have had migraines for 40 years, with minimal frequency until peri-menopause, when they increased 3-4 days a week, 20 hrs ago. Father suffered minimally with migraines. Cause for me mostly are food items, including gluten. In last year, I take 50-100mg of B2(riboflavin) WITH any food, and 99% do not get a migraine. Sometimes I feel fatigued, rather than a migraine, and this mostly happens in the afternoon. My daily chemistry varies, so migraines vary in manifestation too. In reading about B2 and migraines, the B2 addresses a genetic defect which causes the inflammation?? Is there any relation of cause to this new CGRP treatment? When I forget to take the B2, and a migraine begins, I IMMEDIATELY act to stop it. I drink a cup of caffeinated coffee which begins helping in 10 minutes. I also take a small bite of a 2.5 my Amerge tablet (naratriptan), maybe 1/5 to 1/4th of it. it takes longer to act. If I can, I get into a bathtub of warm water, which also contributes to ending the migraine. It appears to calm my system of distract my brain, helping to turn around the neurological thing going on. Instead of a bath, an ice bag (gel bag iced in the freezer) on the back of the head helps to shut the migraine down too. Earlier mentioned by a man, he waits to determine if it is a migraine. I never do that anymore, and do better when I immediately begin to treat the symptons. Waiting makes it more difficult to stop. Even waiting 5 minutes can make it harder, as the migraine is then "engaged". Some of my migraines start within an hour of a specific food, and sometimes 4-5 hours later. When I am aware of symptons, some migraines escalate very quickly to pounding and throbbing, thus harder to shut down. With the B2 i have not experienced nausea or the worst of migraines i used to get. So, I am curious if the CGRP solution is about a genetic situation.
Glad to hear you’ve found help with Riboflavin. It shows promise for migraine but there is a lack of placebo controlled studies as with many potentially very helpful supplements for migraine. I haven’t seen any studies or evidence linking Riboflavin with the correction of a genetic mutation that leads to migraine.
The CGRP antibodies are not a genetically based treatment. They are monoclonal antibodies (as explained in the article) which target the release of CGRP which occurs during a migraine attack.
I am currently using botox injections and have good success, down to 8-10 migraine days from 20+ days a month. I use zomig for acute medication. Very excited about the new medications and curious how they compare to botox in price as well as results.
Congratulations on your success Darlene.
I applaud the research to help control the actions of CGRP with respect to migraines. What is frustrating is that while searching for a pharmacologic bandaid to treat a symptom (migraine headaches), there is little to no effort to understand the WHY. What that is behind the CGRP being released by the Trigeminal Nucleus in the first place. We know that Sensory (afferent) nerve feedback through the Trigeminal nerve branches overloads the Trigeminal Nucleus to elicit CGRP release. This sensory overload is often due to a structural imbalance of the dental occlusion, accompanied cervical/cranial misalignment, and daytime airway accommodation. While the patient is receiving the CGRP antibody treatment, all of these structural problems will still exist in. You may effectively stomp out the symptom but you are ignoring the fire that caused the symptom. Not understanding, diagnosing and informing the patient of their functional stress and strain of their head, neck, and jaws (and back, hips and feet) allows further damage to occur to the components mentioned.
My point is that while this news is fantastic, pharmacologic treatments are only masking the actual problem. Stabilizing the entire stomatognathic system, stablizing postural balance, restoring or creating an improved physiology, is more complicated and often requires collaboration of health care providers. But it offers a chance to eliminate the CAUSE of the Migraine while stopping structural damage from continuing. It means understanding that nothing in the body happens in a bubble and we as doctors need to consider the strain to integrated systems that create the symptoms we wish to treat.
Dr. Curtis Westersund D.D.S.
Calgary, Alberta, Canada
Hi Dr. Westersund, it would be great to have more research looking into the cause. That is an ongoing challenge I’ve written about in other places on the website.
Likewise, I think you’d find that there are many people who have neck and jaw issues yet don’t have migraine. So the ‘true cause’ may be beyond these strucutures in many circumstances. Having said that, I’ve found the better my neck and jaw (clenching) are the less vunerable and fewer triggers I have with migraine.
Based on your article, does it seem like the drugs that target CGRP itself are safer than those that target the receptor? Thanks!
There’s not any evidence suggesting any difference in safety profile so far… so too early to say at this point Lisa.
Carl, is there any data on success of these treatments on vestibular migraine? I have not tolerated any acute medications and am currently getting Botox treatments and my doctor is recommending I start these injections
Hi Jennifer, good question. I haven’t seen any migraine sub-type research specific to migraine except with the migraine with or without aura. In both cases is effective. For vestibular migraine I’d also assume effective based on what I’ve seen but more evidence over time will reveal the actual reality.
I am allergic to Triptans. Before I go to the Neurologist, I need to know if I will get adverse reactions if I decide to get the injections.
Hi Donna, only your doctor who should have your medical history will be able to tell if a reaction is likely or not. I would expect them to say that “we don’t know for sure”. And carefully monitor your response. Severe side effects were not common in the research studies.
I suffer from vestibular migraine with auras like tingling, photosensitivity, noise sensitivity, smell and some tinnitus on and off. I do not suffer from any migraine headaches, but I have constant dizziness 24/7. My dizziness is not episodic but rather constant. In addition, my eyes see colored patches and flashes of light. I feel rocking not only in my head, but I also feel my surroundings rotate and rock around me. Is there any evidence that one of the CGRP’s might help my dizziness? I have tried all kinds of medications with no success. Thanks
I haven’t seen any specific studies but I have heard feedback from other people with vestibular migraine and yes, it can definitely help and is worth trying! Also, like the triptans, if one CGRP doesn’t work, it is still work trying the others. There is hope!
Hi Carl, my 26 year old daughter has been struggling to cope with chronic migraine for many years now. Botox initially helped, but is not as effective now. A supra-orbital stimulator implant only gave marginal relief and also became ineffective after time. She is allergic to Triptans and Topomax gives her kidney stones. She has tried Aimovig, but unfortunately has had no relief. We are keen to trial Ajovy as many people on the migraine facebook site have indicated that Ajovy has worked for them whereas Aimovig has not. My question is, when is it going to be available in Australia? I am hoping it will be soon.
Sorry to hear about your daughter. Ajovy is approved by the TGA in Australia (the equivalent of the FDA in the US). So is Emgality. So these two options are available at full price. I’m working with Headache Australia to recommend and provide rationale why we believe they should be covered on the PBS. They are actually accepting patient submissions for a few more days. See this link for details on how to submit your comments https://headacheaustralia.org.au/pbac/ if you subscribe to Headache Australia or join their Facebook Support Group you’ll receive regular updates.
Thank you for this very helpful article and conversations in the chats. It is very helpful. I suffer from chronic migraine, up to 25 days a month. I’ve tried most treatments – but not CGRP. I live in South Africa. Does anyone know of a good headache specilialist/Dr/Neurologist I can go and see??
I have seen a few neurologists and not had much luck – they are dedicated but feel I know quite a lot more about Migraine than they do.
Any info on a good Dr or centre I can go to in SA would be a huge help. I went to The Headache clinic and it was a total scam unfortunately!
Thanks, everyone! Stay strong!
Sorry to hear you haven’t found a good option yet. I don’t know the South African Headache specialist scene very well but I would ask for a neurologist who a) attends the international headache conference every 2 years (or the American Headache meetings) or b) is familiar with the CGRPs monoclonal antibodies. You ideally want to work with someone who is across the latest best practices and treatments and is happy to see migraine patients.