CGRP Treatment Reduces Frequency of Migraine in Patients With Multiple Sclerosis

Recently published in the International Journal of MS Care, a retrospective cohort study showed a significant reduction in migraine frequency and a favorable safety profile for patients with comorbid multiple sclerosis (MS) who took calcitonin gene-related peptide (CGRP) monoclonal antibodies. With no observed worsening of MS symptoms, the findings suggest CGRP monoclonal antibodies are a safe and effective therapy for episodic or chronic migraine in this patient population.¹

In the study, investigators identified 27 individuals with MS (women, 88.9%) and chronic (88.9%), or episodic (7.4%), or unspecified migraine (3.7%) who received treatment with a CGRP monoclonal antibody. Of these, 63% reported a reduction in their migraine frequency of greater than 75%. Of the participants, 82% were cotreated with a disease-modifying therapy (DMT) for their MS and in 37% of these, the DMT used was also a monoclonal antibody.

"The main findings of our study included the significant reduction in migraine frequency (number of migraine/headache days per month) when patients warranting migraine prophylaxis were treated with CGRP monoclonal antibodies and the favorable tolerance of these agents in the cohort of patients with MS and migraine,” senior author Janice Y. Maldonado, MD, assistant medical director of the MS Center and professor of neurology at University of South Florida (USF), told NeurologyLive®. "Also, the fact that most individuals in the cohort were on disease modifying treatment for MS, a 1/3 taking a monoclonal antibody-type, and adding the CGRP monoclonal antibody treatment for migraine did not have any impact on MS symptoms or disease course or known adverse interactions with MS treatments."

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At the 2022 Consortium of Multiple Sclerosis Centers (CMSC) Annual Meeting, June 1-4, in National Harbor, Maryland, investigators presented data from a retrospective medical record review at the USF MS center. Adult patients with both MS and chronic, episodic, or unspecified migraine and had received treatment with a CGRP monoclonal antibody were included in the study. The researchers collected data from the participants between June 2018 and January 2022. The primary outcomes included migraine frequency before and after use of CGRP monoclonal antibodies and reported adverse events (AEs) by participants while on CGRP treatment.

Only 11% of participants on CGRP monoclonal antibodies treatment reported mild AEs such as muscle spasms, constipation, headache. Among the patients that reported a reduction in headache frequency (n = 25), 7.4% reported between 50% and 75% reduction in headache frequency and only 22.2% reported less than 50% reduction in headache frequency. Overall, authors noted that 63% of participants reported a greater than 75% reduction in migraine frequency with CGRP treatment. Notably, investigators did not observe a significant difference in reduction of headache frequency between patients who were on dual monoclonal antibody therapy compared with those who were not.

"It was surprising to find such astounding efficacy- migraine frequency was reduced by 75% in more than half of the cohort! The implications of these results are the individuals with MS and comorbid migraine who need to start a prophylactic treatment for migraine can consider CGRP monoclonal antibodies," Maldonado told. "This could mean for patients to attain such significant relief and control over one of 2 chronic disabling conditions can provide individuals with MS and migraine hope for improved quality of life!"

In terms of limitations, the research was underpowered and MS subtypes were not ascertained among the participants. Authors noted that most of the patients had no documented MS exacerbations, meaning that their MS may not have been active enough to affect the safety of CGRP monoclonal antibody treatment. Investigators assessed CGRP monoclonal antibodies in this patient population but not small-molecule inhibitors or gepants. This was because at the time of data collection, that specific information was not available on the market for a long period of time, according to the authors. It was also noted that this study was constrained by a limited long-term follow up and had the longest duration of treatment with CGRP monoclonal antibodies at only 42 months. Despite the limitations, authors noted that this study expanded on the previous research, further demonstrating that the CGRP monoclonal antibodies can be safely used in patients with comorbid MS.²

"It would be desirable that the next steps in research would include a larger sample size to allow looking at MS sub-types and long term follow up in a randomized design. We were not able to observe the effect of the CGRP small-molecule inhibitors (gepants) in our cohort because they were not yet available; therefore, that data is lacking at present," Maldonado told.

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REFERENCES
1. Mason A, Fragapane L, Toledo-Nieves Z, Moreo N, Aungst A, Robertson D, Maldonado J. Use of Calcitonin Gene-Related Peptide Monoclonal Antibodies for the Treatment of Migraines in Individuals With Multiple Sclerosis. Int J MS Care. 2023; doi: https://doi.org/10.7224/1537-2073.2023-013
2. Gonzalez-Martinez A, Bose G, Chitnis T. Anti-CGRP therapies for migraine in multiple sclerosis patients. Mult Scler. 2022;28(13):2149-2150. doi:10.1177/13524585221096353