Calcitonin gene-related peptide receptor or ligand (CGRP) antagonists for preventive treatment of migraine in adults

Agent	Dose (range)	Maximum dose	Notes
Parenteral monoclonal antibodies^*
Erenumab	70 to 140 mg SUBQ once monthly	140 mg SUBQ once monthly	Auto-injector
Fremanezumab	225 mg SUBQ once monthly or 675 mg SUBQ once every 3 months	225 mg SUBQ once monthly or 675 mg SUBQ once every 3 months	Auto-injector Dosing monthly or every 3-month interval
Galcanezumab	120 mg SUBQ once monthly (following initial 240 mg SUBQ loading dose)	120 mg SUBQ once monthly	Auto-injector May also be used for cluster headache suppression (dosing regimen differs)
Eptinezumab	100 to 300 mg IV infusion once every 3 months	300 mg IV infusion once every 3 months	IV infusion over ≥30 minutes (in clinic) Dosing every 3 months
Oral small molecule antagonists
Atogepant	Episodic migraine: 10 mg, 30 mg, or 60 mg orally once daily Chronic migraine: 60 mg orally once daily	60 mg orally once daily	Dose adjustment required for kidney impairment Significant drug interactions^¶
Rimegepant	Episodic migraine: 75 mg orally every other day	75 mg orally every other day	May also be used for acute migraine treatment (dosing regimen differs) Orally disintegrating tablet Dose adjustment required for kidney impairment Significant drug interactions^¶

CGRP antagonists may be effective preventive treatment for patients with marked disability from frequent migraines and/or those who do not respond to other preventive agents. Long-acting intravenous and subcutaneous formulations may be preferred by patients who have difficulty with daily preventive therapy. CRGP antagonists are avoided in patients with significant cardiovascular disease and pregnancy. Refer to UpToDate topics and drug monographs for full clinical use, precautions, and additional dosing details.

CYP3A4: cytochrome p450 3A4 isoform; IV: intravenous; P-gp: P-glycoprotein drug efflux pump; SUBQ: subcutaneous.

* Injection site reactions and constipation are most frequently reported adverse effects for parenteral agents.

¶ Small molecule "gepants" undergo CYP3A4 metabolism and are substrates of P-gp efflux pump. Specific interactions may warrant dose adjustment or avoidance of some combinations. To determine potential interactions for a specific patient's medication list, use the drug interactions program included within UpToDate.

Data from: UpToDate Lexidrug. More information available at https://online.lexi.com/.

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Calcitonin gene-related peptide receptor or ligand (CGRP) antagonists for preventive treatment of migraine in adults