The Consequences of Discontinuing CGRP Inhibitors in Migraine Patients

Pharmacists must understand the value of monitoring changes in quality of life and headache frequency to help facilitate the decision to continue, discontinue, or restart migraine prophylaxis.

Migraine headaches are a leading cause of disability that affect 1 in 6 Americans. Migraines negatively impact quality of life, daily functioning, and productivity.1

Prophylactic treatment can reduce the frequency, severity, and duration of migraine attacks. Patients may benefit from prophylaxis if they routinely suffer from migraines (e.g., they have more than 6 headache days per month), are unresponsive to or unable to tolerate abortive therapies, or experience severe disability.1

Guidelines recommend discontinuing prophylactic treatment if headaches are under control for at least 6 to 12 months.2 Examples of FDA-approved drugs for migraine prophylaxis include beta-blockers propranolol and timolol; anticonvulsants divalproex sodium and topiramate; and injectable calcitonin-gene related peptide (CGRP) inhibitors erenumab (Aimovig), galcanezumab (Emgality), and fremanezumab (Ajovy).1

In December 2021, The Journal of Headache and Pain published a prospective, longitudinal cohort study to evaluate 61 patients for changes in health-related quality of life after discontinuing a CGRP inhibitor for migraine prophylaxis.3

Patients completed a headache-specific questionnaire (i.e., Headache-Impact-Test 6) and generic questionnaires (i.e., EuroQol-5-Dimension-5-Level, Short-Form 12) at the time of last monoclonal antibody injection, 8 weeks later, and 16 weeks later. Results revealed that after CGRP inhibitor discontinuation, the impact of headache increased, and general wellbeing declined.

Additionally, after treatment discontinuation, monthly migraine days (MMDs) increased. At the time of last injection, the mean MMDs was 8.59. At 16 weeks after the last injection, it increased to 12.84, a number similar to baseline MMDs prior to treatment.

Surprisingly, researchers found that patients can suffer from impaired quality of life during treatment discontinuation, even without a worsening of migraine frequency. This suggests that headache frequency is not the only factor influencing quality of life in patients with migraines. Fear of another attack, avoidance of certain activities, and social stigmatization are additional factors that can negatively impact patients’ lives.

Researchers observed that discontinuing erenumab led to a greater impairment of quality of life compared to discontinuing galcanezumab or fremanezumab. The exact reason is unknown, but it may be due to erenumab’s shorter elimination half-life of 21 days, as opposed to 27 days for galcanezumab and 30 days for fremanezumab.

Conclusion

The cessation of CGRP inhibitor treatment can negatively impact patients with migraines. Pharmacists must understand the value of monitoring changes in quality of life and headache frequency to help facilitate the decision to continue, discontinue, or restart migraine prophylaxis.

About the Author

Natalie Espeso is a 2022 PharmD candidate at the University of Connecticut.

References

  1. Peters GL. Migraine overview and summary of current and emerging treatment options. Am J Manag Care. 2019;25(2):S23-S34. Accessed January 12, 2022. https://www.ajmc.com/view/migraine-overview-and-summary--of-current-and-emerging-treatment-options
  2. Ha H, Gonzalez A. Migraine headache prophylaxis. Am Fam Physician. 2019;99(1):17-24. Accessed January 12, 2022. https://www.aafp.org/afp/2019/0101/p17.html
  3. Terhart M, Mecklenburg J, Neeb L, et al. Deterioration of headache impact and health-related quality of life in migraine patients after cessation of preventive treatment with CGRP(-receptor) antibodies. J Headache Pain. 2021;22(1):158. doi:10.1186/s10194-021-01368-7