Last reviewed: February 2019
Last updated: October  2018
16 Oct 2018

Erenumab approved in the EU for the prevention of migraine

Erenumab, a novel treatment for migraine prevention, has been approved by the European Medicines Agency (EMA) for the prophylaxis of migraine in adults who have at least 4 migraine days per month.

Erenumab is a first-in-class fully human monoclonal antibody that works by inhibiting the calcitonin gene‑related peptide (CGRP) receptors. The CGRP is believed to play a causal role in the pathophysiology of migraine. Erenumab is administered as a once-monthly subcutaneous injection. According to the EMA, the benefit of erenumab treatment is its ability to reduce the number of monthly migraine days. In two trials involving 667 patients with chronic migraine and 955 with episodic migraine, patients with chronic migraine showed a reduction of 2.5 monthly migraine days on average compared to placebo after 3 months of treatment. For patients with episodic migraine the reduction was either 1.3 or 1.8 days, depending on the dose taken. The most common side effects were injection site reactions, constipation, muscle spasms and pruritus.

The US Food and Drug Administration approved erenumab in May 2018 for the preventive treatment of migraine in adults.

See Management: approach

Original source of update

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • prolonged headache
  • nausea
  • decreased ability to function
  • headache worse with activity
  • sensitivity to light
  • sensitivity to noise
  • aura
Full details

Other diagnostic factors

  • vomiting
  • unilateral
  • throbbing sensation
Full details

Risk factors

  • family history of migraine
  • high caffeine intake
  • exposure to change in barometric pressure
  • female sex
  • obesity
  • habitual snoring
  • stressful life events
  • overuse of headache medications
  • lack of sleep
  • low socio-economic status
  • allergies or asthma
  • hypertension
  • hypothyroidism
  • diet
Full details

Diagnostic investigations

1st investigations to order

  • clinical diagnosis
Full details

Investigations to consider

  • erythrocyte sedimentation rate (ESR)
  • lumbar puncture (LP)
  • cerebrospinal fluid (CSF) culture
  • CT head
  • MRI brain
Full details

Treatment algorithm

INITIAL

migraineur presenting to the emergency department with persistent symptoms

ACUTE

mild-moderate symptoms: non-pregnant

severe symptoms: non-pregnant

pregnant

ONGOING

frequent recurring severe/disabling symptoms: non-pregnant

frequent recurring severe/disabling symptoms: pregnant

Contributors

Authors VIEW ALL

Associate Professor of Neurology

Chief

Headache Division

Department of Neurology

Duke University Medical Center

Durham

NC

Disclosures

TAC was an unpaid site PI for the Alder study ALD403-CLIN-011 (monoclonal Ab against CGRP as treatment for chronic migraine), which ended in July 2017. TAC served as a paid consultant for Eli Lilly Co. in November 2016. In 2017 he served as a paid consultant for Alphasights, a global healthcare consulting organization, regarding migraine headache diagnosis and treatment. He has provided expert testimony regarding headache disorders for a legal case in 2015, and expects to be paid to provide expert testimony on headache disorders in 2018 for a legal case relating to the diagnosis, treatment, and standard of care for headache disorders.

Dr Timothy Collins would like to gratefully acknowledge Dr Ann Donnelly, the previous contributor to this monograph. AD declares that she has no competing interests.

Peer reviewers VIEW ALL

Professor

Family and Community Medicine

University of Kansas School of Medicine

Wichita

KS

Disclosures

AW declares that she has no competing interests.

Director

Walton Headache Center

Augusta

GA

Disclosures

MSH declares that he has no competing interests.

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