Monthly erenumab jabs promising for chronic migraine, medication overuse headaches

Monthly injections of erenumab help induce and sustain remission of chronic migraine and medication overuse headaches (CM-MOH), as shown in the phase IV INOVA study.

In a cohort of 584 individuals (mean age 44 years, 82.5 percent female) with nonopioid CM-MOH who had inadequate response to at least one preventive treatment, MOH remission rate at 6 months was 69.1 percent with erenumab 140 mg, 60.3 percent with erenumab 70 mg, and 52.6 percent with placebo. [JAMA Neurol 2024;doi:10.1001/jamaneurol.2024.3043]

The odds of achieving remission at 6 months were twofold greater with erenumab 140 mg vs placebo (odds ratio [OR], 2.01, 95 percent CI, 1.33–3.05; p<0.001), while no significant difference was observed between the lower erenumab dose and placebo (OR, 1.37, 95 percent CI, 0.92–2.05; p=0.13).

A significant reduction in average monthly acute headache medication use occurred in parallel in the erenumab arms vs the placebo arm (140 mg vs placebo: 9.4 vs 6.6 days; p<0.001; 70 mg vs placebo: 7.8 vs 6.6 days; p=0.03).

MOH remission throughout the double-blind treatment phase was sustained in 119 participants (61.3 percent) in the erenumab 140 mg arm, 96 (49.5 percent) in the erenumab 70 mg arm, and 73 (37.6 percent) in the placebo arm.

Meanwhile, mean migraine days over 4–6 months decreased by 9.0 days from a baseline of 18.6 days in the erenumab 140 mg arm and by 7.5 days from a baseline of 19.2 days in the erenumab 70 mg arm as compared with a decrease of 6.0 days from a baseline 18.6 days in the placebo group (p<0.001 and p=0.01, respectively). The proportion of patients who achieved a 50-percent reduction in mean migraine days was 56.2 percent, 41.8 percent, and 26.3 percent, respectively.

As for safety, the incidence of adverse events (AEs) was consistent with the known safety profile of erenumab. Treatment-emergent AEs occurred in 66.8 percent of patients in the combined erenumab arms, with constipation (15.2 percent) and COVID-19 (13.9 percent) being the most common.

“The study findings demonstrate that erenumab treatment can yield and sustain high rates of MOH remission, reduce acute medication consumption, and improve participants’ functionality over a 6-month observation period,” the investigators said.

“These results align with previously conducted post hoc analyses from several phase 2 and 3 studies and a prospective real-life cohort study showing that monoclonal antibodies targeting the CGRP pathway provide sustained efficacy in participants with and without acute medication overuse,” they added. [Headache 2023;63:730-742; Cephalalgia 2021;41:340-352; Headache 2021;61:125-136; Neurologia 2021;36:611-617]

Monoclonal antibodies that target the CGRP pathway could minimize potential drug–drug interactions, which offers a distinct advantage in the MOH population who may be taking multiple medications to treat their headaches as well as comorbidities, the investigators noted.

“Patients with CM-MOH are a highly burdened population in which high headache frequency is associated with substantial impact on functioning, pain interference, and quality of life… This trial provides first, to our knowledge, American Academy of Neurology class I evidence for a preventive therapy in CM-MOH,” they said. [Headache 2021;61:351-362]