Commentary
Video
Andrew Charles, MD, outlines why calcitonin-gene-related peptide (CGRP) antagonists are increasingly favored as first-line migraine treatments and how pharmacists play a key role in patient education and support.
In an interview with Pharmacy Times®, Andrew Charles, MD, director of the UCLA Goldberg Migraine Program, explained his view on the role of pharmacists in counseling patients on using calcitonin-gene-related peptide (CGRP) antagonists as a first-line treatment for preventing migraines. The discussion was based on his presentation "Yes: Should CGRP Antagonists Be First Line for Migraine Treatment?" which was showcased as part of a debate-style discussion with another expert in the field who disagreed with Charles' stance. The session took place during the "Controversies in Neurology Plenary Session" on Saturday, April 5, at the American Academy of Neurology 2025 Annual Meeting in San Diego, California.
"I think pharmacists should play a primary role in educating patients about these treatments." - Andrew Charles, MD
Charles discussed how the use of CGRP antagonists is growing, particularly in patients without comorbidities or those intolerant to traditional therapies due to adverse effects such as cognitive dysfunction or weight gain. Charles emphasizes that CGRP-targeting medicines are generally well-tolerated among users and that pharmacists play a key role in ensuring safe, effective use as their popularity rises.
Pharmacy Times: Why are CGRP antagonists appropriate for first-line migraine treatment compared with other available therapies? Are there important considerations for patients before beginning treatment?
1. CGRP antagonists offer a well-tolerated alternative to traditional migraine therapies, with fewer and less severe side effects.
2. Pharmacists are instrumental in counseling patients on treatment expectations, side effect management, and proper usage.
3. As CGRP therapies become more widely adopted, clinicians are witnessing life-changing benefits for patients, marking a breakthrough era in headache care.
Andrew Charles, MD, Director, UCLA Goldberg Migraine Program: There certainly are very important considerations. The important considerations are comorbidities, where, for example, if someone has hypertension or depression, we might consider other therapies that would treat both migraine and these other conditions. But I will say that for those who don't have these comorbidities or for those whom we have worries about side effects of these other therapies, which in some cases can be considerable, that's a very clear situation where we believe that the CGRP-targeting therapies should be considered as a first-line approach. Some of the side effects of some of the traditional therapies include cognitive dysfunction, weight gain, hair loss, and tremor—really significant side effects. Whereas we certainly have seen some side effects with some of the CGRP-targeting therapies, namely constipation for some of them, for the most part, they're generally very well tolerated, and that's one of the main reasons that we're so enthusiastic about recommending them for patients. The other situation where we would consider them as first line is if they have medication overuse, which is a condition where they're frequently using acute medications. This is a situation where it's been shown now that these therapies can be useful even in patients who have medication overuse, and that's not the case for most of the traditional migraine non-specific treatments.
Pharmacy Times: How can pharmacists counsel patients who experience migraines on the proper use of CGRP antagonists?
Charles: Well, I think that's one of the other things I would say, that it's very important for pharmacists to understand these therapies. I think pharmacists should play a primary role in educating patients about these treatments. I'm very much in favor of having involvement of pharmacists in treatment education for patients. I would say again, understand some of the side effects that could happen. For the monoclonal antibodies, it's really typically simply injection site reactions. Apart from that, though, again, constipation for some individuals is significant, and in a very small percentage of patients, we see nausea. We rarely see hypertension, and it's rarely clinically significant. One other consideration is that in patients with severe Raynaud's phenomenon, that can be a situation where patients may experience adverse effects from these. Apart from that, again, they're generally very well tolerated and very safe. I think pharmacists can feel comfortable in counseling patients about the efficacy and safety of these treatments. I would also just say that, in general, I think it behooves them to really be aware of these because their use in migraine patients is growing and I think will continue to grow. We would be quite pleased to have pharmacists on board with our appropriate use of these treatments.
Pharmacy Times: Is there anything else that you would like to add?
Charles: No, I'll just say these are extraordinarily exciting times for the field of headache medicine, where we have a host of new treatment approaches. Some of the words that we're hearing, and I said that this morning, that I've heard more in the last 5 years than in the previous decades of my practice, are the words, "My life has changed." Really, that's what we're after as clinicians: to change the lives of our patients for the better. We're really happy to be in a time when we have multiple new tools to change people's lives.
