What is Ajovy (fremanezumab) used for?

Ajovy (Fremanezumab) for Migraine Prevention

Ajovy (fremanezumab) is a calcitonin gene-related peptide (CGRP) monoclonal antibody FDA-approved for the preventive treatment of migraine in adults.

Mechanism and Administration

Fremanezumab works by selectively binding to both isoforms of calcitonin gene-related peptide (CGRP), a neuropeptide involved in the central and peripheral pathophysiological events in migraine 1. It is administered as a subcutaneous injection with two dosing options:

• 225 mg once monthly, or
• 675 mg once quarterly (administered as three consecutive 225 mg injections) 2

Ajovy is available in two forms:

• Prefilled autoinjector
• Prefilled syringe

Both delivery methods have demonstrated bioequivalent pharmacokinetic profiles with similar safety and tolerability 3.

Place in Treatment Algorithm

According to the American College of Physicians (ACP) 2025 guideline, Ajovy is recommended as a second-line therapy for migraine prevention 4. The treatment algorithm is as follows:

1. First-line treatments (try one of these first):

   • Beta-blockers (metoprolol or propranolol)
   • Antiseizure medication valproate
   • Serotonin and norepinephrine reuptake inhibitor venlafaxine
   • Tricyclic antidepressant amitriptyline

2. Second-line treatments (if first-line fails or is not tolerated):

   • CGRP monoclonal antibodies (including fremanezumab/Ajovy)
   • CGRP antagonist-gepants (atogepant or rimegepant)

3. Third-line treatment:

   • Topiramate (if both first and second-line treatments fail or are not tolerated) 4

Efficacy

Fremanezumab has demonstrated significant efficacy in:

• Reducing monthly migraine days
• Decreasing the need for acute migraine medications
• Improving quality of life and reducing migraine-related disability 5

Notably, Ajovy has shown effectiveness even in patients who previously failed 2-4 other preventive medication classes, with mean reductions in monthly migraine days of 3.7-4.1 days compared to 0.6 days with placebo 5.

Special Populations

Ajovy has demonstrated efficacy in patients with:

• Chronic migraine with comorbid depression, showing significant reductions in headache days of moderate-to-severe intensity 6

Contraindications and Precautions

• Contraindicated in patients with hypersensitivity to fremanezumab or any components of the formulation 2
• Not recommended in patients with history of stroke, subarachnoid hemorrhage, coronary heart disease, inflammatory bowel disease, chronic obstructive pulmonary disease, or impaired wound healing 7
• Pregnancy: It is unknown if Ajovy will harm an unborn baby. A pregnancy registry exists to collect safety information 2
• Breastfeeding: It is unknown if Ajovy passes into breast milk 2

Perioperative Considerations

Unlike triptans (which should be held on the day of surgery), CGRP monoclonal antibodies including fremanezumab can be continued throughout the perioperative period. Surgical treatment can be scheduled at any time during the treatment cycle, including on the day of injection 4.

Adverse Effects

The most common side effects include:

• Injection site reactions (pain, induration, erythema)
• Potential allergic reactions (including itching, rash, and hives) which can occur within hours and up to 1 month after administration 2

Storage and Handling

• Store refrigerated at 2°C to 8°C (36°F to 46°F)
• May be kept at room temperature up to 30°C (86°F) for a maximum of 7 days
• Protect from light
• Do not freeze or shake 2

Ajovy represents an important advancement in migraine prevention with its targeted mechanism of action and convenient monthly or quarterly dosing options, particularly for patients who have failed or cannot tolerate traditional preventive medications.