New migraine preventives: which patients will benefit, when, and how?

In an interactive symposium at #WCN2021, leading experts discussed practical approaches to managing migraine with an audience of physicians. The topics covered included when to prescribe new preventive treatments, which patients will likely benefit the most, and how best to evaluate treatment response.

CGRP mAbs: Which patients may benefit most?

Associate Professor Piero Barbanti, San Raffaele University-IRCCS, Rome, Italy asked the audience “Based upon your experience, which patient populations may benefit most from calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs)?”

More than half of responders said that patients who had failure or tolerability issues with prior preventive treatment may benefit most from CGRP mAbs. Other populations who may derive most benefit from CGRP mAbs were thought to be patients whose daily functioning and quality of life (QOL) is highly impacted by the disease, and patients with acute medication overuse.

Patients with prior preventive treatment failure or tolerability issues may benefit most from CGRP mAbs


When to prescribe CGRP mAbs?

Professor Shuu-Jiun Wang, National Yang Ming Chiao Tung University, Taiwan asked the audience when they prescribe CGRP mAbs, and over 80% of the physicians replied that they prescribe CGRP mAbs following treatment failure with 2 or more previous preventives.

Most physicians prescribe CGRP mAbs following treatment failure with ≥2 previous preventives

Real world evidence collected from patients with chronic migraine (CM) and high frequency episodic migraine (EM) in Italy shows that CGRP mAbs are effective in patients who have failed 3 or more other classes of preventive medications.1 Other studies show that CGRP mAbs are effective in treatment-resistant patients with high disability,2 and in patients with acute medication overuse.3,4 CGRP mAbs significantly reduce migraine headache days in patients with both EM and CM,5-7 and some patients may convert from CM to EM with CGRP mAb therapy.8

Some patients may convert from chronic to episodic migraine with CGRP mAb therapy


What is the best way to evaluate treatment response?

Professor Dawn Buse, Albert Einstein College of Medicine, USA asked the audience what parameters they use to evaluate response to treatment when starting patients on CGRP mAb therapy. Two-thirds of physicians who responded said that they measure treatment response by reduction in disability/migraine burden both during and between attacks, while the other one-third measure QOL improvement.

CGRP mAb therapy reduces both ictal and interictal burden of migraine

Updated guidelines from the American Headache Society state that several factors can define success in migraine prevention, which include significant reduction in frequency of headache/migraine days, significant decrease in attack duration or severity, improved response to acute treatment, reduction in migraine-related disability and improvement in functioning and migraine-related QOL.9 And treatment response to CGRP mAbs has been demonstrated in clinical trials showing improvements in disability,10 QOL,11 and improvement in interictal burden.12


Educational financial support for this Satellite symposium was provided by Lilly.


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Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.


  1. Barbanti P, et al. Headache 2021 Jul 26 [Epub ahead of print]. doi:10.1111/head.14194.
  2. Tepper SJ, et al. Eur J Neurol 2020;27(Suppl 1):445. Abstract EPR3051.
  3. Silberstein SD, et al. J Headache Pain 2020;21:114.
  4. Tepper SJ, et al. Neurology 2019;92:e2309‒e2320
  5. Silberstein SD, et al. J Headache Pain 2019;20:75.
  6. Detke HC, et al. Neurology 2018;91:e2211‒e2221.
  7. Ferrari MD, et al. Lancet 2019;394:1030‒1040.
  8. Lipton RB, et al. Headache 2018;58(Suppl 2):162. Abstract PS25.
  9. Ailani J, et al. Headache 2021;61:1021‒1039.
  10. Buse DC, et al. Cephalalgia 2018;38:1622‒1631.
  11. Lipton RB, et al. Neurology 2020;95:e878‒e888.
  12. Garcia-Azorin D, et al. Eur J Neurol 2020; 27(Suppl 1):160. Abstract EPR1100.