The CGRP Revolution

Calcitonin gene-related peptide (CGRP) inhibitors represent the first class of medications designed specifically for migraine prevention. As a preventive treatment approach, they have transformed care for many patients since their introduction in 2018.

What Is CGRP?

CGRP is a protein found throughout the nervous system that plays a central role in migraine:

  • Released during migraine attacks by trigeminal nerve fibers
  • Causes blood vessel dilation in the brain
  • Promotes neuroinflammation
  • Transmits pain signals in the trigeminal system
  • Levels are elevated in people with chronic migraine even between attacks
  • Researchers are also studying PACAP, a related neuropeptide, as a future treatment target

Types of CGRP Inhibitors

Monoclonal Antibodies (Prevention)

These are injected medications that block CGRP or its receptor for weeks at a time:

  • Erenumab (Aimovig) - blocks the CGRP receptor; monthly self-injection
  • Fremanezumab (Ajovy) - blocks CGRP itself; monthly or quarterly injection
  • Galcanezumab (Emgality) - blocks CGRP; monthly self-injection
  • Eptinezumab (Vyepti) - blocks CGRP; quarterly IV infusion

Gepants (Acute and Preventive)

These are oral medications that block the CGRP receptor:

  • Ubrogepant (Ubrelvy) - acute treatment only
  • Rimegepant (Nurtec ODT) - approved for both acute treatment and prevention
  • Atogepant (Qulipta) - daily oral preventive

Who Are They For?

CGRP inhibitors are typically recommended for:

  • Patients with 4 or more migraine days per month
  • Those who have tried and failed 2 or more traditional preventive medications
  • Patients who cannot tolerate side effects of other preventives
  • Those with medication overuse headache (can use while reducing other medications)

What to Expect

Effectiveness

  • About 50% of patients see their migraine days cut in half
  • Some patients respond within the first month
  • Full effect may take up to 3 months
  • A small percentage of patients become completely migraine-free

Side Effects

Generally very well tolerated:

  • Injection site reactions (redness, pain) - most common, mild
  • Constipation - particularly with erenumab
  • Allergic reactions - rare but possible
  • No significant drug interactions with most medications

What They Do Not Do

  • They do not cure migraines
  • They do not work for everyone - about 30-40% of patients do not respond
  • They should be used alongside lifestyle management for best results
  • Stopping treatment usually leads to return of previous migraine frequency

Cost and Access

CGRP inhibitors are expensive medications. Insurance coverage varies:

  • Many insurers require step therapy (trying cheaper options first)
  • Manufacturer patient assistance programs are available
  • Some patients may qualify for specialty pharmacy discounts
  • Discuss options with your neurologist and insurance provider

Tracking Treatment Response

When starting a CGRP inhibitor, tracking your migraine frequency, severity, and acute medication use is essential. Using one of the best apps to track migraine symptoms can streamline this process. This data helps you and your doctor evaluate whether the treatment is working and make informed decisions about continuing, switching, or adjusting your treatment plan.

Start tracking your treatment response today with the Migraine Trail, a free tracking tool designed to help you monitor medications, track migraine triggers, and share clear reports with your neurologist.