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Table 4 Use of anti-CGRP monoclonal antibodies for migraine prevention

From: Consensus of the Hellenic Headache Society on the diagnosis and treatment of migraine

• In patients with high frequency episodic migraine who have failed at least two of the available medical treatments or who cannot use other preventive treatments because of comorbidities, adverse events 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, adverse events or poor compliance, we suggest the use of erenumab, fremanezumab, or galcanezumab;
• In patients with high frequency 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 adding 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 adding erenumab, fremanezumab, or galcanezumab and considering later withdrawal of the oral drug. In patients with chronic migraine who are on treatment with onabotulinumtoxinA with inadequate treatment response we suggest stopping 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 adding oral preventive drugs;
• In patients with high frequency episodic or chronic migraine, we suggest considering pausing treatment with erenumab, fremanezumab, and galcanezumab after 6–12 months of treatment in order to evaluate the migraine status; if migraines recur to the pre-treatment status or to an undesirable level for the patient, treatment re-administration is suggested.
• In patients with chronic migraine and medication overuse, we suggest using erenumab, fremanezumab, and galcanezumab before or after withdrawal of acute medications;
• In patients with migraine, we suggest avoiding 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;
• In patients with migraine on treatment with anti-CGRP monoclonal antibodies, there is no need for testing for binding and/or neutralizing antibodies.
  1. Adapted from Sacco et al., 2019 [6] with changes
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