Concurrent Use of Emgality and Aimovig is Not Standard Practice
Using Emgality (galcanezumab) and Aimovig (erenumab) together is not recommended as standard therapy, as both are CGRP monoclonal antibodies indicated for monotherapy in migraine prevention 1, 2. The 2025 ACP guidelines emphasize initiating monotherapy for episodic migraine prevention, with no mention of combining two CGRP monoclonal antibodies 3.
Rationale Against Concurrent Use
Both medications target the same CGRP pathway—Aimovig blocks the CGRP receptor while Emgality binds the CGRP ligand itself 1, 2. Using both simultaneously:
- Lacks FDA approval or guideline support for combination therapy
- Provides no established additive benefit since they target the same biological pathway through different mechanisms
- Increases cost substantially without proven incremental efficacy
- Has no safety data from clinical trials evaluating this specific combination
The FDA labels for both agents indicate use as monotherapy for migraine prevention, with no provisions for combining with another CGRP monoclonal antibody 1, 2.
When Dual CGRP Therapy Might Be Considered
The only scenario with emerging evidence involves combining a CGRP monoclonal antibody with an oral gepant (atogepant or rimegepant)—not two monoclonal antibodies together. A 2026 retrospective study found that combining one monoclonal antibody with one oral gepant in chronic migraine patients showed:
- Median reduction in headache days (p=0.031)
- 22% of patients achieved ≥50% reduction in headache days
- No significant increase in adverse events (p=0.219) 4
However, this study specifically evaluated monoclonal antibody + gepant combinations, not two monoclonal antibodies like Emgality + Aimovig.
Recommended Approach
If a patient fails one CGRP monoclonal antibody:
Switch to a different CGRP monoclonal antibody (e.g., from Aimovig to Emgality or vice versa)—real-world data shows comparable efficacy between erenumab and galcanezumab in refractory chronic migraine 5
Consider adding an oral gepant (atogepant or rimegepant) to the existing monoclonal antibody if switching alone is insufficient 4
Evaluate for medication overuse headache before escalating therapy
Ensure adequate trial duration (3-6 months) before declaring treatment failure, as some patients are late responders 6
Safety Concerns
The 2026 dual CGRP study reported one ischemic stroke case in a patient with multiple risk factors 4. While causality is unclear, this highlights the need for caution when intensifying CGRP pathway blockade, particularly in patients with:
- Cardiovascular risk factors
- History of Raynaud's phenomenon (a known risk with CGRP agents) 2
- Hypertension (which can worsen with galcanezumab) 2
Bottom Line
Do not combine Emgality and Aimovig. If one CGRP monoclonal antibody fails, switch to another monoclonal antibody or consider adding an oral gepant—but do not use two monoclonal antibodies simultaneously. This approach lacks evidence, guideline support, and FDA approval while substantially increasing costs and potential risks without proven benefit.