Determine the effectiveness of anti-CGRP pharmacotherapy added to multimodal management in patients with refractory migraine referred to the tertiary headache clinic at the University of Washington.

In May 2018, the FDA approved the first anti-CGRP medication erenumab-aooe for treatment of episodic and chronic migraine. This was not previously studied in patients with high frequency migraines. Two other agents, fremanezumab-vfrm and galcanezumab- gnlm became available soon after. All three rely on monoclonal antibodies that target CGRP or its receptor in trigeminal pain pathways. Our tertiary headache center treats many refractory headache patients with a high frequency of migraines. A recent poster publication (Preston, 2018) suggested erenumab-aooe was not effective in patients who had failed 3 classes of preventive medications and presented with more than 25 headache days per month. We wanted to determine the effectiveness of these medications as part of  multimodal treatment.

A retrospective chart analysis review using the EPIC database of patients who were prescribed anti-CGRP agents. All patient data were reviewed by headache providers who collected information about previous care and provided definitive diagnoses using ICHD-3 criteria.

We analyzed N=87 patients total who received anti-CGRP agents, 75 female and 12 male. N=43 patients had 25 or more headache days per month, 38 female and 5 male. N=22 out of these 43 patients show at least 50% reduction of migraine days, and there 11 patients were hyper-responders who improved 75% or more from baseline. 

In a tertiary care population of migraine patients with high frequency migraine all 3 anti-CGRP agents worked in about 50% of patients with high frequency migraine. 11/43 patients were hyper-responders and 5 patients  went from 30 migraine days per month to zero. We conclude that this treatment should be considered in all patients even patients with refractory migraine who have high frequency migraine.