Savvas-Ilias Christofilos, Theodoros Mavridis, Viktor Gkotzamanis, Sofia Vasilopoulou, Christina I Deligianni, Dimos-Dimitrios Mitsikostas
{"title":"Repurposed versus disease-specific medicinals for the prophylaxis of migraine: an updated systematic review.","authors":"Savvas-Ilias Christofilos, Theodoros Mavridis, Viktor Gkotzamanis, Sofia Vasilopoulou, Christina I Deligianni, Dimos-Dimitrios Mitsikostas","doi":"10.1080/17581869.2025.2509474","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Gepants, selective antagonists of the calcitonin gene-related peptide (CGRP) receptor, and monoclonal antibodies targeting CGRP or its receptor (anti-CGRP mAbs) are promising migraine treatments, demonstrating superior tolerability than traditional preventives. While their efficacy over placebo is established, their comparative benefit-risk profiles remain to be fully elucidated.</p><p><strong>Objective: </strong>To indirectly compare the benefit-risk ratios of gepants with anti-CGRP mAbs and repurposed preventives.</p><p><strong>Methods: </strong>A comprehensive search of PubMed/MEDLINE and ClinicalTrials.gov was conducted to identify phase-3, placebo-controlled trials of gepants (atogepant, rimegepant), anti-CGRP mAbs (eptinezumab, erenumab, fremanezumab, galcanezumab), and traditional treatments (propranolol, topiramate, onabotulinumtoxinA). The number needed to treat (NNT) for achieving ≥50% reduction in migraine days and the number needed to harm (NNH) for adverse effects were calculated to determine the likelihood to help versus harm (LHH) values.</p><p><strong>Results: </strong>Twenty-seven studies were included: 15 of mAbs, 4 of gepants, 2 of onabotulinumtoxin A, and 6 of standard treatments. Atogepant and fremanezumab exhibited the highest LHH in episodic migraine, and galcanezumab and eptinezumab performed favorably in chronic migraine concerning treatment discontinuation and treatment-related adverse effects.</p><p><strong>Conclusions: </strong>Anti-CGRP/R medications present a more favorable benefit/risk ratio than traditional treatments. These findings, combined with individual patient histories and preferences, can inform clinical decision-making.</p>","PeriodicalId":20000,"journal":{"name":"Pain management","volume":" ","pages":"425-439"},"PeriodicalIF":1.5000,"publicationDate":"2025-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12218587/pdf/","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Pain management","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.1080/17581869.2025.2509474","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2025/5/30 0:00:00","PubModel":"Epub","JCR":"Q4","JCRName":"CLINICAL NEUROLOGY","Score":null,"Total":0}
引用次数: 0
Abstract
Background: Gepants, selective antagonists of the calcitonin gene-related peptide (CGRP) receptor, and monoclonal antibodies targeting CGRP or its receptor (anti-CGRP mAbs) are promising migraine treatments, demonstrating superior tolerability than traditional preventives. While their efficacy over placebo is established, their comparative benefit-risk profiles remain to be fully elucidated.
Objective: To indirectly compare the benefit-risk ratios of gepants with anti-CGRP mAbs and repurposed preventives.
Methods: A comprehensive search of PubMed/MEDLINE and ClinicalTrials.gov was conducted to identify phase-3, placebo-controlled trials of gepants (atogepant, rimegepant), anti-CGRP mAbs (eptinezumab, erenumab, fremanezumab, galcanezumab), and traditional treatments (propranolol, topiramate, onabotulinumtoxinA). The number needed to treat (NNT) for achieving ≥50% reduction in migraine days and the number needed to harm (NNH) for adverse effects were calculated to determine the likelihood to help versus harm (LHH) values.
Results: Twenty-seven studies were included: 15 of mAbs, 4 of gepants, 2 of onabotulinumtoxin A, and 6 of standard treatments. Atogepant and fremanezumab exhibited the highest LHH in episodic migraine, and galcanezumab and eptinezumab performed favorably in chronic migraine concerning treatment discontinuation and treatment-related adverse effects.
Conclusions: Anti-CGRP/R medications present a more favorable benefit/risk ratio than traditional treatments. These findings, combined with individual patient histories and preferences, can inform clinical decision-making.