Data Show Fremanezumab Converts Chronic Migraine to Episodic, Improves Quality of Life for Patients

Individuals with chronic migraine (CM) experience severe headaches for a minimum of 15 days per month for at least 3 months, leading to significant detrimental effects on physical, personal, and professional aspects of life.^1,2 Episodic migraine (EM) manifests as less frequent headaches, is less disruptive, and is easier to manage and treat.^1,2 Over time, however, EM can progress to CM and CM can remit to EM, but researchers do not currently know why or how this occurs.^2,3 Health care professionals therefore strive to convert CM to EM and prevent EM progression to CM.^1,2

Woman with a migraine | Image credit: © vectorfusionart | stock.adobe.com

Researchers have established that migraine headaches are initiated by the release of calcitonin gene-related peptides (CGRPs) in the trigeminal afferent neurons.³ The FDA has approved 4 monoclonal antibodies directed against either the CGRP (fremanezumab, galcanezumab, and eptinezumab) or its receptor (erenumab) for preventing migraine.³ By disrupting the interaction between CGRP and its receptor, these antibodies prevent the development of a migraine headache.³ The American Headache Society (AHS) recommends that health care professionals use these agents as first-line therapy for preventing migraine.^3,4

Clinical researchers determined that two-thirds of patients treated with erenumab and more than half of patients treated with galcanezumab or fremanezumab were converted from CM to EM.^5-7 Although the study with erenumab failed to determine the conversion predictors,⁵ the study with fremanezumab determined that prior use of topiramate or botulinum toxin, or concomitant use of other preventative medications or medication overuse, was less likely to convert CM to EM.⁷

Tudela-Tomas and colleagues aimed to corroborate these findings and determine likely predictors of conversion from CM to EM.⁸ The authors performed a real-life observational study with fremanezumab (Ajovy; Teva) in working age and botulinum toxin-resistant patients to determine conversion from CM to EM and likely predictors for this change.⁸ They searched digital health records of patients in Spain to identify those who were diagnosed with CM, were 18 to 65 years of age, and were treated with fremanezumab injection (225 mg/month) for at least 3 months. Fifty-four patients consented to an interview and provided information regarding monthly headache days (MHD), daily headache hours (DHHs), monthly symptomatic medication days (MSMDs), symptomatic medication overuse (SMO), and headache intensity on a numerical rating scale (NRS).⁸

The authors of the study compared these parameters before and after treatment with fremanezumab. The authors also collected information related to sex, age, previous failure with erenumab, medications used for symptomatic control of migraine headache, whether amitriptyline was used as prophylactic, and whether patients had hypertension, type I diabetes, depression, or anxiety.⁸

The authors determined that 40 patients (74.1%) converted from CM to EM. Additionally, patients who were either taking anti-anxiety medications or who had failed to convert to EM with previous erenumab (Aimovig; Amgen) treatment were significantly less likely to convert to EM when receiving treatment with fremanezumab.⁸

The authors further evaluated the benefit of fremanezumab in parameters used to assess migraine symptoms and reported statistically significant reduction in all patients with respect to MHD, DHHs, MSMDs, and SMO, but not in NRS. All patients reported a significant reduction in MHD and MSMDs, but only the patients who converted to EM reported a significant reduction in DHHs and SMO.⁸

Conclusions

The authors concluded that treatment with fremanezumab 225 mg/month for at least 3 months can improve the quality of life for all patients suffering from CM with respect to MHD and MSMDs. Additionally, this treatment converted 74.1% of patients with CM to EM and reduced DHHs and SMO.⁸ The authors also concluded that patients who failed conversion from CM to EM with prior erenumab treatment or those who suffer from anxiety are less likely to convert with fremanezumab treatment. However, the authors call for more studies using multiple centers, more patients, longer study duration, and assessing other factors that may predict the conversion from CM to EM by fremanezumab.

References

1. Cleveland Clinic: Chronic Migraine. Accessed August 7, 2024. https://my.clevelandclinic.org/health/diseases/9638-chronic-migraine

2. Lipton RB, Silberstein SD. Episodic and chronic migraine headache: breaking down barriers to optimal treatment and prevention. Headache. 2015 Mar; 55 Suppl 2: 103-122. doi: 10.1111/head.12505_2

3. Aditya S and Rattan A. Advances in CGRP monoclonal antibodies as migraine therapy: a narrative review. Saudi J Med Med Sci. 2023 Jan-Mar; 11(1):11-18. doi: 10.4103/sjmms.sjmms_95_22

4. Charles AC, Digre, KB, Goadsby PJ, Robbins MS, Hershey A, on behalf of The American Headache Society. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: An American Headache Society position statement update. Headache. 2024; 64: 333-341. https://doi.org/10.1111/head.14692

5. Ornello R, Casalena A, Frattale I, Caponnetto V, Gabriele A et al. Conversion from chronic to episodic migraine in patients treated with erenumab: real-life data from an Italian region. J Headache Pain. 2020 Aug 15; 21(1): 102. DOI: 10.1186/s10194-020-01171-w

6. Altamura C, Brunelli N, Marcosano M, Aurilia C, Egeo G et al. Conversion from chronic to episodic migraine in patients treated with galcanezumab in real life in Italy: the 12-month observational, longitudinal, cohort multicenter GARLIT experience. J Neurol. 2022 Nov; 269(11): 5848-5857. DOI: 10.1007/s00415-022-11226-4

7. Lipton RB, Cohen JM, Bibeau K, Galic, M, Seminerio MJ et al. Reversion from chronic migraine to episodic migraine in patients treated with fremanezumab: post hoc analysis from HALO CM study. Headache. 2020 Nov-Dec; 60(10): 2444-2453. doi: 10.1111/head.13997

8. Tudela-Tomas J, Ramos-Guerrero R-M, Rodriguez-Mateos M-E. Reversion of chronic to episodic migraine in working age and botulinum toxin-resistant patients treated with fremanezumab: a real life study. Brain Behav. 2024 Jul: 14 (7): e3631. DOI: 10.1002/brb3.3631