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

Simona Sacco, Faisal Mohammad Amin, Messoud Ashina, Lars Bendtsen, Christina I Deligianni, Raquel Gil-Gouveia, Zaza Katsarava, Antoinette MaassenVanDenBrink, Paolo Martelletti, Dimos-Dimitrios Mitsikostas, Raffaele Ornello, Uwe Reuter, Margarita Sanchez-Del-Rio, Alexandra J Sinclair, Gisela Terwindt, Derya Uluduz, Jan Versijpt, Christian Lampl, Simona Sacco, Faisal Mohammad Amin, Messoud Ashina, Lars Bendtsen, Christina I Deligianni, Raquel Gil-Gouveia, Zaza Katsarava, Antoinette MaassenVanDenBrink, Paolo Martelletti, Dimos-Dimitrios Mitsikostas, Raffaele Ornello, Uwe Reuter, Margarita Sanchez-Del-Rio, Alexandra J Sinclair, Gisela Terwindt, Derya Uluduz, Jan Versijpt, Christian Lampl

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.

Keywords: Calcitonin gene-related pathway; Guideline; Migraine; Monoclonal antibodies; Prevention.

Conflict of interest statement

Competing interests are reported in Supplemental File S1.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
PRISMA Flowchart of study selection
Fig. 2
Fig. 2
Risk of bias summary for each included study
Fig. 3
Fig. 3
Forest plots of comparison: 1 Monoclonal antibodies vs placebo - Episodic migraine
Fig. 4
Fig. 4
Forest plots of comparison: 2 Monoclonal antibodies vs placebo - Chronic migraine

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