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Table 19 Recommendations about the use of anti-calcitonin gene-related peptide monoclonal antibodies in subjects with migraine

From: European headache federation guideline on the use of monoclonal antibodies acting on the calcitonin gene related peptide or its receptor for migraine prevention

Clinical question Recommendation Strength of the recommendation
1. When should treatment with anti-CGRP monoclonal antibodies be offered to patients with migraine?
  In patients with episodic migraine who have failed at least two of the available medical treatments or who cannot use other preventive treatments because of comorbidities, side effects or poor compliance, we suggest the use of erenumab, fremanezumab, or galcanezumab
In patients with chronic migraine who have failed at least two of the available medical treatments or who cannot use other preventive treatments because of comorbidities, side effects or poor compliance, we suggest the use of erenumab, fremanezumab, or galcanezumab
Experts’ opinion
2. How should other preventive treatments be managed when using anti-CGRP monoclonal antibodies in patients with migraine?
  In patients with episodic migraine, before starting erenumab, galcanezumab or fremanezumab we suggest to stop oral preventive drugs unless the patient had a previous history of chronic migraine before prevention; in this case, we suggest to add the anti-CGRP monoclonal antibody to the ongoing treatment and to re-assess the need of treatment withdrawal
In patients with chronic migraine who are on treatment with any oral drug with inadequate treatment response we suggest to add erenumab, fremanezumab, or galcanezumab and to consider later withdrawal of the oral drug
In patients with chronic migraine who are on treatment with onabotulinumtoxinA with inadequate treatment response we suggest to stop onabotulinumtoxinA before initiation of erenumab, fremanezumab, or galcanezumab
In patients with chronic migraine who are on treatment with erenumab, fremanezumab, or galcanezumab and who may benefit from additional prevention we suggest to add oral preventive drugs
Experts’ opinion
3. When should treatment with anti-CGRP monoclonal antibodies be stopped in patients with migraine?
  In patients with episodic migraine, we suggest to consider to stop treatment with erenumab, fremanezumab, and galcanezumab after 6–12 months of treatments
In patients with chronic migraine, we suggest to consider to stop treatment with erenumab, fremanezumab, and galcanezumab after 6–12 months of treatments
Experts’ opinion
4. Should medication overuse be treated before offering treatment anti-CGRP monoclonal antibodies to patients with chronic migraine?
  In patients with chronic migraine and medication overuse, we suggest to use erenumab, fremanezumab, and galcanezumab before or after withdrawal of acute medications Experts’ opinion
5. In which patients anti-CGRP monoclonal antibodies are not to be used?
  In patients with migraine, we suggest to avoid anti-CGRP monoclonal antibodies in pregnant or nursing women, in individuals with alcohol or drug abuse, cardio and cerebrovascular diseases, and with severe mental disorders Experts’ opinion
6. Should binding and/or neutralizing antibodies be monitored?
  In patients with migraine on treatment with anti-CGRP monoclonal antibodies, we suggest not to test binding and/or neutralizing antibodies in daily clinical practice; we suggest to further study the possible implications of binding and/or neutralizing antibodies Experts’ opinion