Fred Cohen, MD

“We looked at how patients were doing after the addition of a CGRP monoclonal antibody—this was done generally 2-3 months after they started&mdash;and they saw, on average, a further decrease of 5.6 headache days per month. When you combine it, this comes to a total decrease of 16.6 monthly headache days.”

Since the approval of the first members of the calcitonin gene-related peptide (CGRP) monoclonal antibody class for migraine prevention, a number of questions have been raised. Despite their efficacy, these agents often are not immediately available for every patient, with the disease needing to be refractory to other treatments first. However, their approval has nonetheless poised the inquiry as to how these medicines might interact in combination approaches.

Some small studies have been conducted to explore single agents in combination with acute treatments that also act on GCRP, such as the case-based work conducted by Mullin et al. on the combined use of rimegepant (Biohaven) and erenumab (Aimovig; Amgen) to treat refractory migraine.

 Now, additional data has been compiled by Fred Cohen, MD, internal medicine resident physician, Department of Medicine, Montefiore Health System, and colleagues on the use of onabotulinumtoxinA (Botox) in tandem with a CGRP in those who require additional preventive treatment.

American Headache Society (AHS) Virtual Annual Scientific Meeting

 on June 13, 2020, the data suggest that patients with chronic migraine receiving treatment with onabotulinumtoxinA can do so safely and effectively. To find out more about the study and its findings, 

1. Mullin K, Kudrow D, Croop R, et al. Potential for treatment benefit of small molecule CGRP receptor antagonist plus monoclonal antibody in migraine therapy. 

. 2020;00:1-5. doi:10.1212/WNL.0000000000008944.

2. Cohen F, Armand C, Vollbracht S. Efficacy and Tolerability of CGRP Monoclonal Antibody Medications in Patients with Chronic Migraine Undergoing Treatment with OnabotulinumtoxinA. 

. 2020;60(S1 suppl). 1-156. doi: 10.1111/head.13854

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The internal medicine resident physician at Montefiore Health System provided an overview of the study he and colleagues conducted on patients using onabotulinumtoxinA and CGRP agents in tandem.

Fred Cohen, MD: OnabotulinumtoxinA and CGRP Combination Treatment

“We knew we had patients getting both, but it wasn’t ever carefully analyzed. One reason there is this lack of information is when they did the CGRP monoclonal antibody trials, they excluded patients that were getting Botox injections.”

Data presented by Fred Cohen, MD, internal medicine resident physician in the department of medicine at Montefiore Health System at the 

 on June 13, 2020, suggest that patients with chronic migraine receiving treatment with onabotulinumtoxinA (Botox) who require additional preventive treatment can be given calcitonin gene-related peptide (CGRP) monoclonal antibody medications safely and effectively.

Ultimately, in a cohort of 153 patients treated with onabotulinumtoxinA, 66 continued to have 14.3 monthly headache days despite significant reductions from baseline headache days prior to treatment with onabotulinumtoxinA (baseline, 25.3 days; reduction, 10.9 days [43%]; 

 <.0001). The add-on of a CGRP therapy was associated with an additional decrease of 5.6 days, equating to an additional 22.3% reduction (95% CI, 4.5—6.7; 

 <.0001) in monthly headache days.  Of the 153-patient study population, 88 (58%) were treated with erenumab (Aimvoig; Novartis), 51 (33%) were treated with galcanezumab (Emgality; Eli Lilly), and 14 (9%) were treated with fremanezumab (Ajovy; Teva).

To find out more about what prompted the study, what the population looked like, and how these data can be interpreted, 

 spoke with Cohen in an interview. He offered insight into the study’s reasoning as well as what research still needs to be done to analyze the combination use of these medicines.

Cohen F, Armand C, Vollbracht S. Efficacy and Tolerability of CGRP Monoclonal Antibody Medications in Patients with Chronic Migraine Undergoing Treatment with OnabotulinumtoxinA. 

The internal medicine resident physician at Montefiore Health System offers insight into the combined use of CGRP medications and Botox to optimize migraine prevention in patients who have inadequate response with Botox alone. 

Author | Fred Cohen, MD

Articles

Fred Cohen, MD: OnabotulinumtoxinA and CGRP Combination Treatment

Fred Cohen, MD: Combining CGRPs and OnabotulinumtoxinA for Migraine Prevention