CGRP Antibodies for Migraine Prevention – Part 1

0:00 [Music]
0:31 good afternoon everyone
0:32 uh my name is dr elizabeth leroux i am
0:36 the chair of migraine canada and it’s my
0:38 pleasure to welcome you
0:40 on this sunday webinar on cgrp
0:43 antibodies
0:44 for migraine prevention a few
0:47 housekeeping things
0:49 um this webinar will be recorded it is
0:52 recorded
0:53 it will be uh posted on our on our
0:55 youtube channel
0:56 and website um it depending on the
0:59 quality it might be re-recorded
1:01 so it might be slightly different than
1:03 what you’re seeing
1:05 uh please do support us by sharing
1:08 our website our facebook if you’re on
1:11 social media
1:12 but also raise awareness about migraine
1:14 in your network
1:18 so remember that this is a webinar on
1:20 medical therapy
1:22 we do provide information and i am a
1:24 neurologist specialized in headache
1:27 but we cannot provide medical advice for
1:29 your specific case
1:30 so the information discussed might not
1:32 apply to you
1:34 and always discuss whatever medical
1:36 therapy you want to try
1:37 with your own health care provider who
1:39 knows everything about your story
1:42 also do not miss our next webinars we
1:44 have two planned exciting ones with
1:47 christy tate nurse practitioner who’s
1:49 going to talk to us about the story of
1:51 migraine diagnostic pitfalls and how
1:53 migraine sometimes
1:54 is not well diagnosed and then um
1:58 november 29th dr suvendrini elena
2:01 who will talk about women migraine and
2:03 advocacy
2:05 so today i want to talk to you about
2:08 different things all right so basics
2:11 about migraine prevention some of you
2:13 might be very familiar with this but
2:14 others might not be
2:16 we’ll talk about the story and the
2:17 science of cgrp
2:19 then we’ll talk about those treatments
2:21 hov emma vig and galilee
2:23 do they work and what type of side
2:25 effects do they have
2:27 and then we’ll talk also about the
2:29 sensitive topic of
2:30 cost and access and insurance coverage
2:33 so some of you might actually
2:35 already be taking these treatments and
2:37 that might be the part that interests
2:39 you
2:39 the most the whole thing should last
2:42 approximately 40 minutes and then i’ll
2:44 be very glad to take your questions
2:46 in the chat box um the best i can of
2:49 course uh
2:50 in a safely manner all right so let’s
2:51 get started so basics of migraine
2:54 prevention so this is the first
2:56 uh part well maybe it will be reassuring
3:00 to you
3:01 if you live with migraine that first is
3:04 a common problem
3:05 and many people live with migraine and
3:08 have difficulty with their sleep
3:10 their work their personal activities
3:12 they do miss
3:13 occasions they do miss work and so in
3:16 this survey done
3:17 in canada you can see that a lot of
3:20 people
3:20 a quarter of them had difficulty
3:23 attending activities
3:25 three-quarters of them know what it
3:27 means to have a bad night because of a
3:29 migraine
3:30 a third of them miss work and a lot of
3:33 them had to adapt their work activities
3:35 because of migraine so migraine symptoms
3:38 have a significant
3:39 impact on someone’s life both
3:42 professional
3:43 and personal of course that depends on
3:46 how much migraine you have if you have
3:49 three migraines per year you may have
3:51 very
3:51 little impact but if you have chronic
3:53 migraine and you have
3:55 20 days per month with a headache or a
3:57 migraine attack
3:59 of course your life will be
4:00 significantly impacted
4:02 so this continuum of frequency is
4:05 typical of migraine
4:06 and if you live with migraine you know
4:08 this but many people
4:10 do not understand that and that’s why
4:12 some people
4:13 will see migraine as just a headache
4:15 that’s just a little nuisance you take
4:17 an advil
4:18 but we all know if you have frequent
4:21 attacks how debilitating
4:22 that can be so when we approach migraine
4:27 therapy and this is also a basic
4:29 there’s always three parts so your
4:31 doctor should address those three parts
4:33 with you
4:34 ideally the behavioral aspect is
4:36 extremely important
4:38 it’s adapting lifestyle managing
4:40 triggers
4:41 stabilizing the brain as much as we can
4:44 to avoid attacks
4:45 treating the attack is the world of
4:47 acute therapy which we won’t talk about
4:49 today
4:50 and then preventive therapy is medical
4:53 approaches to stabilize the brain
4:56 you may some of you might have seen our
4:58 previous webinar which
5:00 is on our youtube channel about the
5:02 causes of migraine
5:03 and i did present this ping pong theory
5:06 of migraine
5:07 the ping pong theory said that migraine
5:10 is
5:11 a problem with the software the chemical
5:13 software of the brain
5:15 and there’s two way really to tackle
5:17 frequent attacks
5:18 the first is to kind of manage
5:21 the load the burden the triggers
5:24 whatever
5:24 is triggering the attack by stabilizing
5:27 your lifestyle
5:28 addressing other diseases psychological
5:32 and physical health and trying to treat
5:35 peripheral problems
5:36 so it’s true that if you have sleep
5:38 apnea or bruxism or depression
5:41 it might lead to more migraine and by
5:44 addressing that
5:45 you might get better but then on the
5:47 other side
5:48 i have lots of patients who do yoga
5:51 they eat perfectly well they they are
5:54 masters of time management
5:56 and still they have frequent attack and
5:59 that’s where
6:00 medical prevention is indicated to kind
6:02 of manipulate the software
6:05 with medications to make your brain more
6:08 resistant
6:08 to migraine attack so you have less of
6:11 them
6:12 which is the ultimate goal so our goal
6:15 when we discuss
6:16 prevention is to decrease the frequency
6:19 and intensity of attacks to improve your
6:22 quality of life
6:23 this is the goal of migraine therapy so
6:26 for example if you live with chronic
6:28 migraine
6:29 means maybe you start with you know 10
6:31 severe days
6:32 12 mile days that’s 22 days with a
6:35 headache or a migraine attack
6:37 you may miss work and attacks might be
6:39 difficult to treat
6:40 so that’s a very disabled baseline
6:43 and then if you have a 50 response i
6:46 will
6:46 go back to this 50 response concept
6:50 well then it means you may go down to
6:52 five severe days
6:53 five mile days maybe you don’t miss work
6:56 anymore
6:56 and you have a tax that you can finally
6:59 control with triptans or
7:01 anti-inflammatories so that’s our goal
7:04 unfortunately so far we do not have
7:08 universal cures one-size-fits-all things
7:10 for migraine
7:11 usually we deal with it we decrease the
7:14 numbers that’s our goal
7:16 i want to do my little pitch on the
7:17 canadian migraine tracker
7:19 a useful tool a free app you can use
7:22 to actually record your attacks with a
7:25 simple
7:26 mild moderate severe one two three
7:28 approach
7:29 this app is actually very handy now
7:32 during covid time
7:33 because you can send your diary to your
7:36 physician
7:37 my patients are doing that they’re
7:39 sending their diary by email
7:41 to me before my their appointment so i
7:44 can review it as i speak on the phone
7:46 with them or
7:47 on telemedicine so if you haven’t tried
7:50 it
7:50 you might consider it also remember and
7:53 we’ll talk about coverage later
7:55 that now we are a bit more inclined to
7:58 be precise about
8:00 migraine evaluation because insurance
8:02 companies
8:03 might ask for precise headache counts to
8:06 see if whatever they’re paying for
8:08 they’re covering for you
8:10 including the antibodies and botox
8:12 therapy
8:13 just to see are you improving so having
8:16 a headache diary
8:17 is medically indicated it’s really
8:20 practical
8:20 but now it may actually become something
8:23 that may lead to coverage issues
8:26 all right so before the cgrp antibodies
8:30 arrived what did we have for treating
8:33 migraine
8:34 and some of you if you’re experienced
8:36 with migraine you probably know those
8:38 names
8:38 right so we have medications medications
8:41 that were not designed to treat migraine
8:44 they were anti-depressants n-type blood
8:47 pressure or anti-hypertension
8:49 anti-seizure or anti-epileptics
8:52 how do they work we don’t necessarily
8:55 know exactly but they do
8:57 all of them manipulate the software of
8:59 your brain
9:00 to make it more resistant to migraine
9:02 and all of them have been tried
9:04 in studies and clinical studies so you
9:07 might
9:08 know the the most commonly prescribed
9:10 are tricyclics like
9:11 amitriptyline or elevil nor triptyline
9:14 or aventil
9:15 just to make our lives easier there are
9:17 always two names to those things right
9:20 so we have also blood pressure pills
9:22 proprano wall or enderol
9:24 natholol or corguard topiramate
9:27 is a very famous one as well and then
9:30 in the second line uh we have other
9:33 options
9:34 then the vaccine verapamil you see the
9:36 names
9:37 right so what your doctor is gonna do
9:40 usually
9:40 is to say okay you need prevention um
9:44 which is which could work for you do you
9:46 have high blood pressure
9:48 very good i’m gonna give you that drug
9:49 that treats blood pressure
9:51 do you have epilepsy i’m gonna give you
9:53 that drug and then you
9:54 start the quest of oral prevention
9:58 why i’m saying that it’s because there’s
10:00 no way for us to know which one’s gonna
10:03 work
10:03 and it’s really jumping after uh
10:07 jumping through multiple hoops to find
10:09 the one that works
10:11 do they work they actually do right
10:14 so it might be if you’re listening this
10:17 webinar it’s because they didn’t work
10:19 for you but they work for 50
10:22 of people so that’s the ballpark we
10:24 learn when we do
10:25 neurology 50 of people
10:28 get a 50 response that’s the ballpark we
10:32 get
10:33 so here i put a half a half kind of in
10:35 10 people who try
10:37 five will have some degree of response
10:39 and five
10:40 will not so that’s better than nothing
10:44 but what do we know we know that if you
10:46 start
10:47 oral prevention after one year and you
10:50 have
10:50 chronic migraine this is data on chronic
10:53 migraine
10:54 well eight over ten people will have
10:57 stopped their drug
10:58 by the end of the year what does that
11:00 mean it’s not great
11:02 it means somehow that people find
11:05 that they do not have benefit enough
11:09 to keep the drug on and maybe they have
11:12 a little benefit
11:13 but they have side effects and they stop
11:15 the drug because of side effects
11:17 so that’s one of the big problem so that
11:20 means that
11:20 instead of having you know let’s say
11:22 five happy campers
11:24 over 10 trying an oral mid we have
11:27 two happy campers who decide to keep the
11:29 drug because five of them did not get
11:32 better
11:32 and maybe two or three of them actually
11:35 had
11:35 disabling side effects so that’s a
11:38 problem
11:39 so we were really hoping in migraine
11:42 world for something better
11:44 to come along and also something that
11:47 was based
11:48 on science and not just serendipity
11:51 okay let’s take a pause little breath
11:55 before we move to the next portion
11:58 the cgrp story so what is cgrp
12:02 it’s calcitonin gene related peptide
12:05 we’ll just call it cgrp this is
12:08 something we all have in our bodies okay
12:10 this is not a toxic product this is
12:12 something that plays
12:13 many roles in our vascular system in our
12:16 skin system
12:17 and of course in our brains right so
12:20 this is something a peptide a protein
12:23 that is normally present in the body and
12:25 it’s not a bad thing it does
12:27 do things for us right but it does play
12:30 a role in migraine
12:32 remember and if you want to see the
12:34 other youtube video
12:36 little pitch here about the cause of
12:38 migraine uh you can go on youtube and
12:40 look at this one
12:41 but just as a reminder the idea is the
12:44 migraine pain
12:45 comes not from the eye or the neck or
12:48 the temples or the jaw
12:50 we think it comes from the meninges and
12:52 the arteries
12:53 inside the brain and those meninges and
12:56 arteries are just
12:57 filled with sensory nerves that can
12:59 cause pain
13:00 and that’s what we think that is the
13:02 cause of the migraine pain the key cause
13:05 why is there pain during a migraine
13:07 attack it’s because the brain
13:10 exposed the triggers decides to sprinkle
13:13 little inflammatory things like natural
13:16 cayenne pepper
13:17 right on your sensitive meninges and
13:19 arteries
13:20 and that leads to inflammation and you
13:23 know inflammation when you have a
13:25 sunburn
13:25 or you cut yourself or you you bruise
13:27 yourself the skin
13:29 becomes very hypersensitive it may
13:31 become swollen and
13:32 red and then something that you know
13:35 doesn’t hurt
13:36 starts to hurt sounds familiar because
13:38 that’s exactly what happens during
13:40 a migraine where your skin might
13:42 actually become
13:43 sensitive and your whole brain is
13:46 actually sensitive to light and sound
13:49 what type of science do we have to prove
13:52 that cgrp is involved
13:54 in migraine let’s say a lot over 20
13:57 years
13:58 we built up i mean not me great
14:01 researchers
14:02 they built up proofs that cgrp
14:05 if you give it to a person with migraine
14:08 it will trigger an attack
14:10 there’s more cgrp in the blood during a
14:12 migraine attack
14:13 and if you block cgrp you block migraine
14:16 so we have a strong we call it
14:19 scientific rational to block cgrp
14:23 how do we block cgrp okay
14:26 so usually we take medications that we
14:29 take they go into our blood they go in
14:30 our system
14:31 and they go and bind different receptors
14:34 and
14:34 and then they exert their action on our
14:37 bodies
14:38 antibodies are just a kind of molecule
14:42 and we have them naturally in our bodies
14:44 um they usually target
14:46 uh infections like viruses viruses
14:49 or bacteria or whatever tumors
14:53 and they activate an immune response so
14:55 they have
14:56 targets and when they see the target
14:58 they stop the target
15:00 so now we have the capacity to create
15:02 antibodies
15:03 to target certain things like cjrp
15:07 or its receptor so that’s how an
15:09 antibody work
15:11 the entire body is nice because it does
15:13 not go through the liver
15:14 or the kidney and it does not interact
15:17 with other medications
15:19 which is very nice
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