Comparative Efficacy of EMGALITY (Galcanezumab) vs AJOVY (Fremanezumab) for Migraine Prevention
Both EMGALITY (galcanezumab) and AJOVY (fremanezumab) are equally effective in reducing migraine days, with both receiving "strong for" recommendations in current guidelines for episodic and chronic migraine prevention. 1
Efficacy Evidence
CGRP Monoclonal Antibodies as a Class
- Both medications are calcitonin gene-related peptide (CGRP) monoclonal antibodies that have demonstrated significant efficacy in migraine prevention
- The 2023 VA/DoD Clinical Practice Guideline upgraded the recommendation for erenumab, fremanezumab, and galcanezumab to "strong for" based on a network meta-analysis of 6,979 patients from 13 RCTs 1
- Both medications effectively reduce:
- Monthly migraine days
- Abortive medication use
- Migraine-related disability
Galcanezumab (EMGALITY) Specific Evidence
- In the EVOLVE-1 trial, galcanezumab reduced monthly migraine headache days by 4.7 days (120 mg dose) compared to 2.8 days with placebo 2
- Galcanezumab demonstrated efficacy even in patients who failed 2-4 previous preventive treatments 3
- Up to 14.3% of patients on galcanezumab 240 mg achieved 100% response (complete elimination of migraine days) in at least one month during clinical trials 4
- Galcanezumab not only reduces frequency but also alleviates severity and associated symptoms of migraine (nausea, vomiting, photophobia, phonophobia) 5
Comparative Evidence
- No head-to-head trials directly comparing galcanezumab and fremanezumab have been published
- Network meta-analyses included in the VA/DoD guideline showed similar efficacy profiles for both medications 1
- Both medications received identical recommendation strength ("strong for") in the most recent guidelines 1
Clinical Application
When to Consider CGRP Monoclonal Antibodies
- Preventive migraine therapy should be initiated when patients have:
- 4 or more migraine days per month, OR
- 2 or more migraine days with significant disability despite appropriate acute treatment 1
Treatment Algorithm
First-line options (try before CGRP monoclonal antibodies):
- Beta-blockers (metoprolol, propranolol)
- Antiseizure medications (valproate)
- SNRIs (venlafaxine)
- TCAs (amitriptyline) 1
Consider CGRP monoclonal antibodies (EMGALITY or AJOVY) if:
- First-line treatments fail or are not tolerated
- Patient has high frequency or severity of migraines
- Patient has significant disability despite acute treatment 1
Administration differences:
- EMGALITY: 240 mg loading dose followed by 120 mg monthly
- AJOVY: 225 mg monthly or 675 mg quarterly
Important Considerations
Safety Considerations
- Both medications have favorable safety profiles compared to traditional preventive medications
- Erenumab (another CGRP monoclonal antibody) has been associated with hypertension in post-marketing studies, but this has not been specifically reported with galcanezumab or fremanezumab 1
- Most common adverse effects are injection site reactions
Cost and Access
- Both medications are substantially more costly than traditional preventive options 1
- Patient preference may favor oral medications over injectable treatments 1
- Insurance coverage and patient assistance programs may influence choice between the two agents
Monitoring and Expectations
- Allow 2-3 months to assess full efficacy of either medication
- Treatment success is typically defined as ≥50% reduction in monthly migraine days
- Consider discontinuation if inadequate response after 3 months of treatment
Conclusion
Based on the most current and highest quality evidence, both EMGALITY and AJOVY demonstrate similar efficacy profiles for migraine prevention with "strong for" recommendations in clinical guidelines. The choice between them should be based on factors such as administration preference (monthly vs. quarterly option), insurance coverage, and individual tolerability.