Is Aimovig (Erenumab) more effective than Ajovy (Fremanezumab) for preventing migraines in patients with a history of cardiovascular disease?

CGRP Monoclonal Antibodies in Patients with Cardiovascular Disease

Aimovig (erenumab) and Ajovy (fremanezumab) should both be avoided in patients with a history of cardiovascular disease, as CGRP monoclonal antibodies present a theoretical risk by inhibiting vasodilation in this population. 1

Evidence for Cardiovascular Contraindication

• CGRP monoclonal antibodies are contraindicated in patients with cardiovascular pathology because these drugs inhibit vasodilation, which could theoretically worsen ischemic events in patients with underlying vascular disease. 1

• The 2021 Nature Reviews Neurology guidelines position CGRP monoclonal antibodies as third-line medications for migraine prevention, to be considered only after failure of first-line options (beta-blockers, topiramate, candesartan) and second-line options (flunarizine, amitriptyline, sodium valproate). 2

• Guidelines recommend screening for cardiovascular disease before initiating triptans, and this same caution extends to CGRP antagonists in patients with established cardiovascular disease. 3

Comparative Safety Data

While there is no head-to-head trial directly comparing Aimovig versus Ajovy in cardiovascular patients, the available evidence suggests:

• Erenumab (Aimovig) demonstrated a vascular safety profile comparable to placebo over 12 weeks in clinical trials, with hypertension adverse events reported in only 0.8% of patients receiving 70 mg and 0.2% receiving 140 mg (compared to 0.9% with placebo). 4

• However, 4 positively adjudicated cardiovascular events occurred during open-label erenumab treatment, including 2 deaths and 2 vascular events, though these occurred in patients who may have had underlying risk factors. 4

• The independent adjudication committee found that vascular adverse events were generally confounded with plausible alternative etiologies, making causality difficult to establish. 4

Alternative Treatment Approach for Cardiovascular Patients

For patients with cardiovascular disease requiring migraine prevention, prioritize the following algorithm:

1. First-line: Propranolol 80-240 mg/day or timolol 20-30 mg/day (unless contraindicated by asthma, heart block, or severe bradycardia). 2

2. Second-line: Amitriptyline 30-150 mg/day, particularly for patients with mixed migraine and tension-type headache. 2

3. Third-line: Topiramate or divalproex sodium/sodium valproate (with monitoring for adverse effects including weight gain, tremor, and teratogenic potential). 2

4. Fourth-line: OnabotulinumtoxinA (Botox) for chronic migraine (≥15 headache days per month), which has no cardiovascular contraindications. 3, 5

Critical Clinical Pitfall

• Never initiate CGRP monoclonal antibodies as first-line therapy in any patient, as they are positioned as third-line options after failure of at least two conventional prophylactic treatments. 2, 3

• The French guidelines specifically note that CGRP antibodies should only be proposed after failure of at least two conventional prophylactic treatments in patients with at least 8 migraine days per month and without cardiovascular pathology. 1

• For acute migraine treatment in cardiovascular patients, avoid triptans and instead use NSAIDs (naproxen 500-825 mg, ketorolac 30 mg IV) or newer gepants (ubrogepant, rimegepant) which have no vasoconstrictor activity. 3, 6