AAN 2025 | Should CGRP antagonists be the first line of treatment for patients with migraine?

Until the launch of anti-CGRP targeting drugs, the drugs we use in migraine prevention were unspecific and unselected, and mostly discovered by serendipity. This, let’s say, unlucky or sometimes dramatic situation accounted for the high proportion of patients discontinuing the treatment. It has been calculated that pulling together beta blockers, tricyclics, and anti-epileptic drugs, the proportion of patients discontinuing the treatment after 16 weeks ranged from 25 to 43%. That means that patients could not be properly treated and could not be treated for a reasonably good period of time. Those CGRP-targeted treatments represent, from a speculative point of view, the first selective and specific agents for migraine prevention. But their excellent efficacy and tolerability ratio allows to treat almost every patient. The adherence is extremely high. The persistence of the effect across multiple months of treatment is excellent. And this also allows us to prolong the treatment for months, sometimes for more than one year, whereas the regulatory rules of the local countries allow. So there is no competition at all between the new anti-CGRP treatment drugs and the traditional standard of care. We acknowledge that some reimbursement issues may emerge, but from a speculative point of view, CGRP treatment drugs should indeed represent the first line of treatment, because after all, the patient asks for an effective, safe and tolerable treatment, and that’s exactly what CGRP targeting drugs represent now.

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