EAN 2025 | Post-hoc analysis of PEARL: early initiation of fremanezumab for the prevention of migraine

Well, one of the main challenges in clinical practice and the questions that we have, what are the predictors for a good response to the medication? So in this study, the PEARL study, we learned some interesting insights from the post-hoc analysis, and that was focused on early initiation. So this post-hoc analysis included 1,128 participants. And in this episodic migraine with less than two prior preventive treatment failures, they had the highest minimum 50% monthly migraine days reduction rates. So that was approximately 68% at month six. And if we compare that to the chronic migraine with at least three failures, previous failures, it was something between 50 to 55. Okay, so we see this numerical difference. But later on, we conducted a multivariate modeling and showed that episodic compared to chronic migraine with an odds ratio of 1.79 and was highly significant. And no prior onabotulinumtoxin type A use, they were significantly associated with the better outcomes, which with post-hoc analysis, with all these reservations, of course, with post-hoc analysis, suggests that the earlier CGRP monoclonal antibody initiation might have an optimized response. Well, I mean, the study, the PEARL study showed that fremanezumab worked across a whole spectrum of migraine, from episodic to chronic. But what we saw in this post-hoc analysis that the patient with episodic migraine and fewer than three prior preventive failures, as well as those who were naive to onabotulinumtoxin type A, they demonstrated the greatest reduction in monthly migraine days. But as I said, overall effectiveness was quite robust across episodic and chronic. There were no new long-term safety concerns. I mean, again, for a moment, it should be cautiously used in patients with known hypersensitivity to monoclonal antibodies, and but then again, given reimbursement and guideline criteria, initiating treatment earlier, I mean, before multiple traditional preventive failures, seems to maximize benefit. But this is something we need to study more. And of course, it all depends on reimbursement and guideline criteria in the different countries across Europe.

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