CGRP Monoclonal Antibodies for Migraine Prophylaxis: Comparative Efficacy

Abstract

Introduction: Anti-CGRP monoclonal antibodies (erenumab, galcanezumab, fremanezumab) revolutionized migraine prophylaxis. Head-to-head comparisons are unavailable, but indirect evidence guides selection. Methods: Network meta-analysis of 15 RCTs (n=8,142) comparing monthly subcutaneous anti-CGRP mAbs versus placebo in episodic (4–14 headache days/month) and chronic (≥15 days/month) migraine. Primary outcome: ≥50% reduction in monthly migraine days (MMD) at 12 weeks. Results: All mAbs outperformed placebo. For episodic migraine: erenumab (RR 2.24, 95% CI 1.84–2.73), galcanezumab (RR 2.32), fremanezumab (RR 2.18). For chronic migraine: erenumab (RR 2.11), galcanezumab (RR 2.48). No significant differences between mAbs. Injection site pain occurred in 12–18%. Discontinuation due to adverse events was low (2–4%). Discussion: All three mAbs have similar efficacy. Choice should be based on dosing convenience (quarterly fremanezumab vs monthly) and comorbid conditions (constipation with erenumab). Conclusion: Anti-CGRP monoclonal antibodies are equally effective for migraine prophylaxis. Individualization is based on schedule and tolerability.