Is there a migraine medication, such as erenumab (monoclonal antibody targeting the calcitonin gene-related peptide receptor), that can be administered as infrequently as once every six months to a year?

Migraine Prevention with Infrequent Administration: CGRP Monoclonal Antibodies

Yes, there are migraine preventive medications that can be administered as infrequently as once every three months, specifically the calcitonin gene-related peptide (CGRP) monoclonal antibodies, with fremanezumab offering quarterly dosing. 1

CGRP Monoclonal Antibodies: The Most Infrequently Dosed Migraine Preventives

CGRP monoclonal antibodies represent a significant advancement in migraine prevention with their infrequent dosing schedules:

• Fremanezumab: Can be administered subcutaneously once quarterly (675 mg) or monthly (225 mg) 1
• Eptinezumab: Administered intravenously once every 3 months (100 or 300 mg) 1
• Erenumab: Administered subcutaneously once monthly (70 or 140 mg) 1, 2
• Galcanezumab: Administered subcutaneously once monthly 1, 3

Clinical Efficacy and Position in Treatment Algorithm

CGRP monoclonal antibodies have demonstrated significant efficacy in reducing migraine frequency:

• They reduce monthly migraine days by approximately 1-3 days compared to placebo 2, 4
• About 40-50% of patients achieve at least a 50% reduction in monthly migraine days 4, 5
• They significantly reduce the use of acute migraine medications 6
• They improve quality of life and reduce migraine-related disability 6

However, according to current guidelines, CGRP monoclonal antibodies are recommended as third-line treatments after failure of first-line and second-line options:

1. First-line preventives: Beta blockers (atenolol, bisoprolol, metoprolol, propranolol), topiramate, or candesartan 1
2. Second-line preventives: Flunarizine, amitriptyline, or sodium valproate (in men only) 1
3. Third-line preventives: CGRP monoclonal antibodies 1

Safety Profile and Considerations

CGRP monoclonal antibodies have demonstrated favorable safety profiles:

• No significant differences in adverse event rates compared to placebo 2
• Low dropout rates in clinical trials 5
• Common side effects include injection site reactions, upper respiratory tract infections, and nasopharyngitis 4

Important Clinical Considerations

• Assessment of efficacy: For CGRP monoclonal antibodies, efficacy should be assessed only after 3-6 months of treatment 1
• Duration of treatment: For most preventive medications, treatment can be considered for pausing after 6-12 months of successful therapy 1
• Contraindications: CGRP monoclonal antibodies are not recommended in patients with a history of stroke, subarachnoid hemorrhage, coronary heart disease, inflammatory bowel disease, chronic obstructive pulmonary disease, or impaired wound healing 1
• Cost considerations: These are newer, more expensive treatments, which may affect accessibility 1

Conclusion

While no migraine preventive medication can be administered as infrequently as once every six months to a year, fremanezumab (quarterly) and eptinezumab (quarterly) offer the most infrequent dosing schedules currently available, making them potentially attractive options for patients who prefer less frequent medication administration.