What is the indication for Erenumab (erenumab) in migraine treatment?

Erenumab Indication for Migraine Prevention

Erenumab is indicated as a second-line therapy for the prevention of episodic migraine in nonpregnant adults who do not tolerate or inadequately respond to first-line preventive treatments. 1

Primary Indications

• Erenumab (Aimovig) is a calcitonin gene-related peptide (CGRP) monoclonal antibody approved for the preventive treatment of migraine in adults 1
• It is specifically recommended as a second-line therapy after failure of first-line treatments including beta-blockers (metoprolol or propranolol), valproate, venlafaxine, or amitriptyline 1
• Erenumab is indicated for both episodic migraine (1-14 headache days per month) and chronic migraine (≥15 headache days per month) 1

Dosing and Administration

• The recommended starting dose is 70 mg administered once monthly by subcutaneous injection 2
• Some patients may benefit from a higher dose of 140 mg monthly, especially those with difficult-to-treat disease and prior treatment failures 2
• In real-world practice, approximately 70% of patients start with the 70 mg dose, and most (77%) remain on their initial dose during the first 6 months of treatment 3

Efficacy

• Erenumab demonstrates significant reduction in:
  • Monthly migraine days compared to placebo (MD -1.32; P < .00001) 4
  • Migraine-specific medication days from baseline (MD -1.41; P < .00001) 4
  • Achievement of ≥50% reduction in monthly migraine days (RR 1.55; P < .00001) 4
• In real-world studies, 71.4% of chronic migraine patients achieved ≥30% reduction in monthly migraine days after 12 weeks of treatment 5
• The 140 mg dose shows numerically better efficacy than 70 mg across multiple migraine outcomes 2, 4

Patient Selection Considerations

• Clinical predictors associated with lower likelihood of response to erenumab include:
  • Chronic migraine (odds ratio 0.63) 6
  • Daily headache (odds ratio 0.41) 6
  • Previous failure of ≥3 preventive migraine medications (odds ratio 0.54) 6
• Higher age is associated with better outcomes (10-year increase: odds ratio 1.22) 6
• Patients with less severe clinical phenotypes tend to respond earlier to treatment 6

Place in Therapy Algorithm

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

   • Beta-blockers (metoprolol or propranolol)
   • Valproate (contraindicated in women of childbearing potential)
   • Venlafaxine (SNRI)
   • Amitriptyline (TCA) 1

2. Second-line treatments (if first-line fails):

   • CGRP monoclonal antibodies including erenumab
   • CGRP antagonist-gepants (atogepant or rimegepant) 1

3. Third-line treatment (if both first and second-line fail):

   • Topiramate 1

Safety Profile

• Erenumab is generally well-tolerated with no significant difference between erenumab and placebo for serious adverse events 4
• Most common adverse events include constipation, injection site reactions, and muscle spasms 5
• Post-marketing studies have shown an increased risk for development or worsening of hypertension, particularly with erenumab 1
• In real-world studies, treatment discontinuation due to tolerability issues occurs in approximately 13.7% of patients 5

Important Considerations

• Consider preventive treatment in patients experiencing significant disability from migraine on ≥2 days per month despite optimized acute treatment 1
• Evaluate efficacy of erenumab after 3-6 months of treatment 1
• Erenumab may be particularly beneficial for patients who have failed multiple prior preventive treatments 2, 6
• Treatment persistence appears to be an important factor in healthcare resource utilization and costs 3
• Monitor for development or worsening of hypertension during treatment 1