Emgality (Galcanezumab) Dosing and Administration for Migraine Prevention
For preventive treatment of migraine in adults, administer Emgality as a 240 mg loading dose (two consecutive 120 mg subcutaneous injections) followed by 120 mg monthly subcutaneous injections. 1
Recommended Dosing Regimen
Initial Loading Dose
- 240 mg as loading dose: Administer two consecutive subcutaneous injections of 120 mg each at the first treatment session 1
- This loading dose approach allows for rapid onset of effect, with clinical benefit demonstrated as early as Day 1 after the first injection 2
Maintenance Dosing
- 120 mg monthly: Following the loading dose, continue with 120 mg subcutaneous injections once monthly 1
- If a dose is missed, administer as soon as possible, then resume monthly dosing from the date of the last injection 1
Administration Technique
Preparation
- Remove Emgality from refrigeration and allow to sit at room temperature for 30 minutes before injection 1
- Do not warm using heat sources such as hot water or microwave 1
- Do not shake the product 1
- Inspect visually for particulate matter and discoloration; do not use if cloudy or particles are visible 1
Injection Sites
- Administer subcutaneously in the abdomen, thigh, back of upper arm, or buttocks 1
- Avoid areas where skin is tender, bruised, red, or hard 1
- Both prefilled pen and prefilled syringe are single-dose devices that deliver the entire contents 1
Clinical Positioning and Evidence
Guideline Recommendations
- CGRP monoclonal antibodies including galcanezumab are third-line agents recommended when first-line (beta blockers, topiramate, candesartan) and second-line (amitriptyline, valproate) preventive treatments have failed or are contraindicated 3
- The American College of Physicians (2025) provides strong recommendations for galcanezumab in prevention of episodic or chronic migraine 3
Efficacy Timeline
- Onset of effect occurs on Day 1 after the first injection, with statistically significant reduction in migraine headache days compared to placebo 2
- Week 1 response: 54-59% of patients achieve ≥50% reduction in monthly migraine headache days by the first week 2
- Sustained benefit: Mean reduction of 4.2-4.3 monthly migraine headache days maintained throughout 6 months of treatment 4
Treatment Evaluation
- Assess response at 2-3 months after initiation, though for CGRP monoclonal antibodies specifically, efficacy should be evaluated after 3-6 months 3
- Monitor using headache calendars to track attack frequency, severity, and migraine-related disability 3
- Consider discontinuing after 6-12 months of successful therapy to determine if ongoing treatment is necessary 3
Safety Considerations
Contraindications
- Serious hypersensitivity to galcanezumab or any excipients is an absolute contraindication 1
- Anaphylaxis and angioedema have been reported in postmarketing surveillance 1
Common Adverse Events
- Injection site reactions are the most common treatment-emergent adverse events, including pain, pruritus, and erythema 4
- These occur at similar or slightly higher rates compared to placebo 4
- Hypersensitivity reactions can occur days after administration and may be prolonged 1
Special Populations
- Not recommended in patients with history of stroke due to potential increased risk of adverse cardiovascular events 5
- Avoid in patients with impaired wound healing 5
Clinical Pitfalls to Avoid
- Inadequate trial duration: Do not discontinue before 3-6 months unless serious adverse events occur, as full therapeutic benefit may take this long to manifest 3
- Improper storage: Failure to allow medication to reach room temperature before injection may increase injection site discomfort 1
- Medication overuse headache: Address concurrent overuse of acute migraine medications, which can interfere with preventive treatment efficacy 3
- Premature discontinuation: Gradual loss of effect occurs after cessation without rebound headache, but patients should be counseled about this expected pattern 6