We need better options for migraine prevention. And, thanks to the persistent researchers who worked so hard on CGRP, we now have a new class of medications, CGRP antibodies. Below is a table of the drugs with the doses, the brand names, and the status in Canada. The three products are currently available in the USA. Another product, eptinezumab, is not yet available in the USA and is not planned to come to Canada.

A few comments on CRGP MABs may be helpful, some applying specifically to Aimovig as it is the only one accessible in Canada for now:

• CGRP MABs have shown efficacy for the prevention of episodic and chronic migraine in adults. As a reminder, Botox has been approved for chronic migraine, but not episodic migraine.
• The response to any drug may vary a lot from one person to the other. Be very careful regarding personal anecdotes shared on social media and remember that the story shared is the story of one person. Please refer to our table based on published results to evaluate 50% and 75% response rates in different subgroups of migraine.
• Aimovig can be prescribed by any licensed physician in Canada, not only neurologists or headache specialists. A family practitioner familiar with headache management can prescribe it. We expect a similar situation for Emgality and Ajovy once they are approved.
• CGRP MABs will be tested on children and teens but no results are available yet. Therefore, they should not be prescribed to patients under 18 years old at present time.
• There are no published results on the effect of CGRP MABs on post-traumatic headache and New Daily Persistent Headache. Hopefully research will progress on these very disabling headaches.
• There are studies on cluster headache with Emgality and Ajovy suggesting a benefit in episodic cluster headache, but not chronic cluster headache. More research needed.
• There are no contra-indications listed in the Health Canada notice for Aimovig, but certain physicians may be reluctant to prescribe it to people with specific medical issues. Have an open discussion with your physician about any decision to start a medication.
• CGRP MABs should NOT be prescribed to pregnant women or women planning to conceive and it is advisable to stop them a few months before conception. Discuss this important topic with your physician.
• There are no available studies on CGRP MABs for hemiplegic migraine. This is a complex topic that should be discussed individually with your physician.
• Access to Aimovig can be facilitated by the Patient Support Program called Aimovig GO. This program includes financial support covering the cost of the drug until the drug insurance company makes a decision.
• The Aimovig GO program is accessible all across Canada, but the prescribing physician must be aware of the program and fill a form to register the patient.
• At present time, the criteria for access to Aimovig GO are 8 days of migraine per month or more and previous failure of two recognized preventives (for side effects or lack of efficacy).
• For patients who have 4-7 migraine days per month, the Aimovig GO program can provide assistance with injection training and co-pay with private insurers.
• The cost of one 70 mg dose of Aimovig is 530 CAD. Pharmacy delivery fees and relevant taxes are usually added. Annual treatment costs could be around 6 000 CAD.
• The co-pay for Aimovig may vary from one drug plan to another. Please discuss this with your physician and your insurance company.
• Public insurers have not yet (as of April 2019) released their decision about the coverage of Aimovig.
• At present time, it is possible to use both Botox and Aimovig for chronic migraine. There is no medical contra-indication to combine them. Research is expected to see if the combination can lead to a benefit to patients. Insurance issues may arise for co-prescription depending on the decisions of insurance companies.
• CGRP MABs are still a new class of drug. It is well known in medicine that once a drug hits the market some side effects may appear more common and some more refractory patients may not respond as well as what has been seen in the studies.
• This being said, more than 200 000 people have been exposed to Aimovig worldwide over the last year. Side effects are closely monitored and medical experience is building.

Written by Dr Elizabeth Leroux, April 2019

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