James AJames A. Charles, MD
Results from a small study show that patients with posttraumatic migraine headache treated with erenumab (Aimovig; Amgen) experienced a statistically significant reduction in monthly headache days (MHD), suggesting the need for larger-scale studies to confirm the findings. Erenumab has been previously FDA-approved for the preventive treatment of migraine with and without aura.

The single-center, 7-person study assessed the effectiveness of erenumab 140 mg  for the reduction of posttraumatic headache (PTH) in patients who developed the migraine phenotype. Erenumab 140 mg was administered to each patient once, with follow up at 2 and 6 months. Notably, only one patient was administered the erenumab dose twice. Among the patients included, 3 had a remote history of migraine 6 months or longer with symptoms that differed from the PTH-induced migraine phenotype. All patients were treated with various preventives, including daily topiramate, amitriptyline, gabapentin, doxepin, venlaxafine, memantine, ibuprofen, naproxen, and ondesterone for at least 4 weeks with no improvement prior to dosing with erenumab. Each patient recorded descriptive headache intensity as well as monthly headache days before and after treatment. Disability was measured by the Head Impact Test-6 (HIT-6) score.

Two months posttreatment, patients experienced a 95% reduction in MHD (standard deviation 1.22, P <.001). Notably, they saw headache remission begin within 1 week of treatment. Prior to the trial, each patient recorded a HIT-6 score of above 60, indicating severe disability. After receiving erenumab, all HIT-6 scores fell below 49, indicating no disability.

“Studies have shown that with conventional migraine treatment of posttraumatic migraine phenotype, 26% of patients obtain relief and 74% experience no relief,” study author James A. Charles, MD, told NeurologyLive. “This is best explained by functional brain MRI showing cortical regions of nociception different than nontraumatic migraine. Since CGRP receptors are ubitquitous in the entire brain, the trigeminal vascular access of CGRP-R monoclonal antibodies with amplification may explain the robust response of erenumab.”

There were no adverse events or relapses reported in the study. Patients resumed their daily activities without any complications. Treatment with erenumab also resulted in the satisfactory reduction of photophobia, nausea, and dizziness.

“These patients were treated with pills, sprays, and injections and did not improve. We used erenumab because it was studied the longest among the 3 CGRP aBs and after one dose, the patients responded quickly with no adverse effects,” Charles said in an interview with NeurologyLive. “One young police officer with severe posttraumatic migraine was pleading to be treated so she could return to work. One week after erenumab 140mg, she was asymptomatic.”

There are currently no FDA-approved treatments for PTH with migraine phenotype. Though the study showed significant efficacy, Charles said that, “Large scale studies are recommended to determine if all patients would be better off receiving erenumab or another monoclonal antibody in the ER at the time of a concussion.”
Reference:
Charles JA. Treatment of posttraumatic headache migraine phenotype with erenumab- an observational study. J Concussion. 2019; 3(1-4). doi:10.1177/2059700219878292.