What are the recommended dosing, administration, monitoring, and contraindications for Aimovig (erenumab) in adult migraine prevention?

Aimovig (Erenumab) for Adult Migraine Prevention

Recommended Dosing

The recommended starting dose of Aimovig is 70 mg subcutaneously once monthly, with escalation to 140 mg monthly for patients who need greater efficacy—particularly those with prior preventive treatment failures, chronic migraine, or medication overuse headache. 1

• Standard dosing: 70 mg subcutaneously once monthly 1
• Higher dosing: 140 mg subcutaneously once monthly for selected patients who may benefit from increased efficacy 1
• Missed dose: Administer as soon as possible, then resume monthly schedule from the date of last dose 1

When to Use 140 mg Over 70 mg

The 140 mg dose demonstrates numerically superior efficacy across multiple migraine outcomes and should be strongly considered in: 2, 3

• Patients with prior preventive treatment failures (the numerical advantage increases with more prior failures) 3
• Patients with chronic migraine 3
• Patients with medication overuse headache (140 mg achieved 69.1% MOH remission vs 52.6% placebo, while 70 mg showed 60.3% remission) 4
• Patients requiring greater reduction in migraine frequency (140 mg reduced migraine days by 3.7 vs 1.8 for placebo; 70 mg reduced by 3.2 days) 5

Administration Instructions

Aimovig is for subcutaneous injection only and is designed for patient self-administration after proper training. 1

Preparation Steps

• Allow to warm: Remove from refrigerator and let sit at room temperature for at least 30 minutes protected from direct sunlight before injection 1
• Do NOT warm using heat sources (hot water, microwave) 1
• Do NOT shake the product 1
• Inspect visually: Solution should be clear to opalescent, colorless to light yellow 1
• Do NOT use if cloudy, discolored, or contains flakes or particles 1

Injection Technique

• Injection sites: Abdomen, thigh, or upper arm 1
• Avoid areas that are tender, bruised, red, or hard 1
• Single-dose delivery: Both autoinjector and prefilled syringe deliver entire contents in one dose 1

Monitoring Requirements

Blood Pressure Monitoring

Monitor blood pressure regularly in all patients on erenumab, particularly those with pre-existing hypertension or cardiovascular risk factors. 1, 6

• Post-marketing data show 23.3% of patients developed worsening blood pressure after erenumab initiation 6
• Patients with atrial fibrillation have 4.9-fold increased odds of BP worsening 6
• New-onset or worsening hypertension can occur and requires monitoring 1
• One case of non-ST elevation MI attributed to hypertensive emergency has been reported 6

Constipation Surveillance

Actively monitor for constipation, especially after the first dose, as serious complications requiring hospitalization or surgery have occurred. 1

• Constipation occurs in up to 3% of patients in clinical trials 1
• Most cases of serious constipation occurred after the first dose, though later onset is possible 1
• Discontinuation should be considered if serious constipation develops 1

Hypersensitivity Monitoring

• Watch for hypersensitivity reactions (rash, angioedema, anaphylaxis) within hours to more than one week after administration 1
• Most reactions are not serious but require vigilance 1

Contraindications

Aimovig is contraindicated in patients with serious hypersensitivity to erenumab-aooe or any excipients, including prior anaphylaxis or angioedema. 1

Guideline Support

The 2024 VA/DoD guideline provides a strong recommendation for erenumab (along with fremanezumab and galcanezumab) for prevention of both episodic and chronic migraine. 7

• Erenumab carries a strong for recommendation for episodic or chronic migraine prevention 7
• This represents the highest level of guideline support among migraine preventive therapies 7

Common Pitfalls to Avoid

• Temperature error: Failing to warm to room temperature causes injection discomfort and may prevent full dose delivery 1
• Underdosing difficult cases: Starting with 70 mg in patients with multiple prior treatment failures when 140 mg would be more appropriate 2, 3
• Missing BP elevation: Not monitoring blood pressure, particularly in patients with cardiovascular risk factors 1, 6
• Ignoring early constipation: Dismissing constipation complaints that could progress to serious complications 1