The Neurology Department of the Marqués de Valdecilla University Hospital (HUMV) has published a study offering new insights to improve preventive migraine treatment with monoclonal antibodies targeting CGRP (Calcitonin Gene-Related Peptide). The research was conducted by neurologists from the Headache Unit, led by Marcos Polanco, first author of the study, together with biotechnologist Gabriel Gárate, whose contribution was essential for the data analysis.
Preventive migraine treatment has undergone a true revolution since the discovery that CGRP is the main driver of migraine pain. This breakthrough led to the commercialization of the first monoclonal antibody acting as a CGRP receptor antagonist, erenumab, seven years ago. Since then, three additional drugs—galcanezumab, fremanezumab and eptinezumab—have been introduced. These also target CGRP but through a different mechanism, blocking the free or circulating peptide instead of its receptor.
Although many patients with refractory migraine respond to these treatments, approximately one-third do not. Previous studies, based on small and heterogeneous samples, suggested that some patients might improve when switching from one antibody to another, but without thoroughly analyzing the factors influencing this response.
Key insights to improve treatment response
In this context, the Valdecilla Headache Unit analyzed antibody switching in 85 patients—the largest series to date—who had not responded to or had not tolerated the initial treatment. The results confirm that nearly one-third of patients with frequent refractory migraine respond to a second antibody, especially when switching to a different mechanism of action.
The study also identifies factors that help predict which patients are more likely to respond. The presence of aura is associated with a higher probability of success, while having tension-type headache or obesity is linked to a lower response. This may be explained by the fact that aura supports a clearer migraine diagnosis, and that obese patients may require higher doses.
These findings have direct implications for clinical practice. On one hand, they confirm that switching monoclonal antibodies is an effective strategy for one in three patients, provided the new drug has a different mechanism of action. On the other hand, they help clinicians better select patients who are more likely to benefit from treatment, such as those with a more “pure” migraine diagnosis and without obesity.
Given the high cost of these therapies, the results also have implications for healthcare efficiency. The authors note that it is not reasonable to continue testing antibodies with the same mechanism of action in patients who have already failed two different options. The study therefore reinforces the importance of moving toward more personalized medicine in migraine management, optimizing resources and improving patients’ quality of life.
