MedeliX
Start asking

European Headache Federation guideline on the use of monoclonal antibodies targeting the calcitonin gene related peptide pathway for migraine prevention – 2022 update

EHF · 2022 · Europe

Source and licence

Authors
Simona Sacco, Faisal Mohammad Amin, Messoud Ashina et al.
Title
European Headache Federation guideline on the use of monoclonal antibodies targeting the calcitonin gene related peptide pathway for migraine prevention – 2022 update
Journal
The Journal of Headache and Pain, 2022
DOI
10.1186/s10194-022-01431-x
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC9188162

Licence statement of the original publication

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Evidence-based recommendations

  • In individuals with episodic migraine we recommend eptinezumab, erenumab, fremanezumab and galcanezumab as preventive treatmentQuality of evidencea: Eptinezumab 100 mg and 300 mg (q): moderate ⨁⨁⨁○ Erenumab 70 mg (m) and 140 mg (m): high ⨁⨁⨁⨁ Fremanezumab 225 (m) and 675 (q): high ⨁⨁⨁⨁ Galcanezumab 120 mg (m) + 240 mg (ld): high ⨁⨁⨁⨁; Strength of the recommendation: Strong ↑↑
  • In individuals with chronic migraine we recommend eptinezumab, erenumab, fremanezumab and galcanezumab as preventive treatmentQuality of evidencea: Eptinezumab 100 mg and 300 mg (q): high ⨁⨁⨁⨁ Erenumab 70 mg (m): high ⨁⨁⨁⨁ Erenumab 140 mg (m): moderate ⨁⨁⨁○ Fremanezumab 225 mg (m): moderate ⨁⨁⨁○ Fremanezumab 675 mg (q): high ⨁⨁⨁⨁ Galcanezumab 120 mg (m) + 240 mg (ld): high ⨁⨁⨁⨁; Strength of the recommendation: Strong ↑↑
  • In individuals with episodic or chronic migraine we recommend erenumab over topiramate as preventive treatment because of better tolerabilityQuality of evidencea: Low ⨁⨁○○; Strength of the recommendation: Strong ↑↑

Expert consensus statements

  • In individuals with migraine who require preventive treatment, we suggest monoclonal antibodies targeting the CGRP pathway to be included as a first line treatment option.
  • In individuals with episodic or chronic migraine there is insufficient evidence to make suggestions regarding the combination of monoclonal antibodies targeting the CGRP with other preventatives to improve migraine clinical outcomes
  • In individuals with episodic or chronic migraine who start a new treatment with one monoclonal antibody targeting the CGRP pathway we suggest evaluating efficacy after a minimum of 3 consecutive months on treatment
  • In individuals with episodic or chronic migraine we suggest considering a pause in the treatment with monoclonal antibodies targeting the CGRP pathway after 12-18 months of continuous treatment. If deemed necessary, treatment should be continued as long as needed. In individuals with migraine who pause treatment, we suggest restarting the treatment if migraine worsens after treatment withdrawal.
  • In individuals with migraine and medication overuse, we suggest offering monoclonal antibodies targeting the CGRP pathway.
  • In individuals with migraine with inadequate response to one monoclonal antibody targeting the CGRP pathway, there is insufficient evidence on the potential benefits of antibody switch but switching may be an option.
  • We suggest avoiding monoclonal antibodies targeting the CGRP pathway in pregnant or nursing women. We suggest caution and decision on a case-by-case basis in the presence of vascular disease or risk factors and Raynaud phenomenon. We suggest caution in erenumab use in individuals with migraine with history of severe constipation.

Abstract

Background: A previous European Headache Federation (EHF) guideline addressed the use of monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) pathway to prevent migraine. Since then, randomized controlled trials (RCTs) and real-world evidence have expanded the evidence and knowledge for those treatments. Therefore, the EHF panel decided to provide an updated guideline on the use of those treatments.

Methods: The guideline was developed following the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed a systematic review and an analysis of the literature, assessed the quality of the available evidence, and wrote recommendations. Where the GRADE approach was not applicable, expert opinion was provided.

Results: We found moderate to high quality of evidence to recommend eptinezumab, erenumab, fremanezumab, and galcanezumab in individuals with episodic and chronic migraine. For several important clinical questions, we found not enough evidence to provide evidence-based recommendations and guidance relied on experts’ opinion. Nevertheless, we provided updated suggestions regarding the long-term management of those treatments and their place with respect to the other migraine preventatives.

Conclusion: Monoclonal antibodies targeting the CGRP pathway are recommended for migraine prevention as they are effective and safe also in the long-term.

Supplementary Information: The online version contains supplementary material available at 10.1186/s10194-022-01431-x.

Contents of the original publication

The section headings of the original.

  • Background
  • Methods
  • Review of the literature
  • Development of evidence-based recommendations
  • Development of the expert consensus
  • Drafting of the statements
  • Final approval of the document
  • Results
  • Evidence-based recommendations
  • Expert consensus statements
  • Conclusions

A question about this guideline?

Medelix answers clinical questions from guidelines and studies – every statement with its source.

Are you the rights holder and object to this reproduction? Write to contact@medelix.ai and we will take the page down promptly. Imprint