CONSENSUS ARTICLE: UPDATED OPINION OF THE HEADACHE SCIENTIFIC PANEL OF THE HELLENIC NEUROLOGICAL SOCIETY ON THE USE OF MONOCLONAL ANTIBODIES AND SMALL MOLECULES TARGETING THE CGRP PATHWAY IN THE PREVENTIVE TREATMENT OF EPISODIC OR CHRONIC MIGRAINE AND CLU

Abstract

Calcitonin Gene-Related Peptide (CGRP) and its receptor (CGRPr) are the targets of a new class of molecules for the treatment of migraine and cluster headache. Four monoclonal antibodies (mAbs) targeting CGRP/CGRPr (fremanezumab, eptinezumab, galcanezumab, erenumab) have been approved for the prophylactic treatment of migraine in the European Union, and thus in Greece as well, and are commercially available in our country. Under certain conditions, they may be reimbursed by the public insurance agency. They share the same indication, namely the prophylactic treatment of migraine in patients with four or more migraine days per month. Furthermore, another small molecule targeting CGRPr (rimegepant) is indicated for both the prophylactic and acute treatment of episodic migraine, while another one (atogepant) is indicated solely for the prophylaxis of migraine. Both molecules are approved in the EU, are commercially available in our country, and are expected to become available for reimbursement. The Headache Sector of the Hellenic Neurological Society, following its previous articles in 2019 and 2023 and in order to facilitate the implementation and use of these drugs in clinical practice, has decided to create this updated consensus article. In this paper, the authors have independently evaluated data from approval and post-approval studies, guidelines from international societies, and the clinical reality in Greece. In the first section of this article, available clinical data on anti-CGRP/r mAbs and small molecules are presented. In the second section, based on clinical criteria, consensus recommendations regarding the initiation, evaluation, and discontinuation of these treatments are provided. These recommendations should be updated no later than three years from now.