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CGRP Medications: Better for Men, or Women?

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CGRP related medications for migraine are helping a lot of people. But if you’re going to try one, which medication should you start with? Does your sex make a difference?

Gepant drugs - a difference between women and men?

This is a question that is rarely asked or studied. That’s why a study review published in the medical journal Cephalalgia this year caught my attention. It was one of many studies on CGRP-related drugs – but in this case it was looking at the difference between men and women.

And in the case of one type of drugs, there was a difference – the “gepants” – that is, CGRP receptor inhibitors/antagonists. The specific drugs we’re talking about are:

  • ubrogepant (Ubrelvy)
  • rimegepant (Nurtec ODT)
  • zavegepant (Zavzpret)

Now, when these medications are used for acute migraine treatment – that is, when they’re taken to stop a migraine attack in progress – the evidence is positive. For women. However, for men, there is not yet enough evidence to show a clear benefit.

That doesn’t mean they won’t work for you – and maybe future studies will show a clearer benefit. But it could be that some of the CGRP medications simply work better in women.

It would be helpful to have further studies here, because if this difference stands up in further trials, it would be an easy way to pop certain types of medication higher on the list, because they’ll have a better chance of success, for you.

What about other CGRP medications? The meds for chronic migraine known as CGRP antibodies (the ones that end in “umab” – like fremanezumab or erenumab) seemed to work well for both sexes. Preventative CGRP medications also seemed to help both men and women, but the authors of the study would like to keep an eye out for differences in future studies.

Again, at this point this information shouldn’t stop you from trying CGRP medications. It may be information that can be added to the other info your doctor has in order to decide which to try first.

That being said, we look forward to future studies. Anytime we can make the path shorter to something that works to fight your migraine, we’re very interested.

It will also be very helpful in the future to find out why this is, so that we can better target migraine attacks.

To check out the study for yourself, click on Evaluation of outcomes of calcitonin gene-related peptide (CGRP)-targeting therapies for acute and preventive migraine treatment based on patient sex (pdf).

Coming Soon: CGRP Antagonist Nasal Spray

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This month the FDA in the USA approved the very first CGRP antagonist nasal spray, brand name Zavzpret. The drug is known as zavegepant. The new medication should be on the market as early as this July.

Zavzpret

You may remember that the “gepant” medications, such as zavegepant, seem to be good abortives – taken during a migraine attack, they fight symptoms at the time (as opposed to preventatives, which of course prevent attacks).

People who would prefer to avoid injections and pills often go to nasal sprays. Many people like the speed of injections, but don’t like the injections themselves. And with migraine nausea, pills can be hard to take.

However, nasal sprays also tend to be very fast-acting. Zavzpret as a medication seems to be pretty fast-acting itself, which is good news for those who want to stop those migraine symptoms from escalating. The most recent study showed relief from pain as quickly as in 15 minutes.

Zavzpret is also very simple to use. It will probably be prescribed as one spray (into one nostril) of 10mg, once. That’s all.

Another advantage of Zaczpret is that there seem to be very few side effects. The most common (though still only a minority of patients experienced it) was a change in your taste – in other words, foods might taste a little funny. This was just temporary.

For more information on Zavzpret:

QULIPTA (Atogepant) Recent Reports

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It’s about time to have an update on QULIPTA, otherwise known as atogepant, a newer migraine preventative.

Atogepant (QULIPTA)

You may remember that we were talking about atogepant back in 2020. At a time when many medications were coming out as injections, atogepant was a bit of a breath of fresh air. A preventative, taken orally, and only taken once a day (10, 30 or 60mg), with or without food. Much more convenient even than many other oral preventatives.

Atogepant was approved by the FDA in 2021, but studies continue. QULIPTA came up at the June 2022 American Headache Society 64th Annual Scientific Meeting a number of times, and we’re learning more about it as it begins to be used more in the general population.

For example, it was found that some patients seem to lose weight when taking atogepant. It’s a minority, but still a significant number. Not only were patients less likely to gain weight, some actually lost weight taking the medication. Something to watch.

It was confirmed once again that you can take atogepant with or without food. The difference seems to be negligible.

It seems that although many patients find their symptoms diminishing in the first month of treatment, others do need to wait 2 or even 3 months before atogepant works for them. And so far, patients taking the preventative for a year seem to still benefit (we’ll keep watching this – remember, the medication is very new!).

A patient who took the COVID-19 mRNA vaccine experienced continuous migraine visual aura, and was successfully treated using atogepant. This may be a useful treatment for migraine symptoms after vaccination, another one to watch.

More studies have been done on the overall safety of QULIPTA. So far, the news is good – it seems to be generally safe. However, as with any medication, it is very important to tell your doctor about any supplements, medications, vitamins, and so on, that you may be taking. This may affect your dosage.

For more information about atogepant, visit the official QULIPTA site here.

Did You Quit Your CGRP Preventative Too Soon?

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Typically, it seems to be a good idea to try any new treatment for three months. But a new study from Italy is suggesting that some patients may be quitting certain treatments too soon.

In this case, we’re talking about CGRP inhibitors that are used as migraine preventatives.

The study was presented at last month’s annual American Headache Society meeting. The study followed patients who were taking anti-CGRP medication for 48 weeks (about 11 months). The overwhelming majority of patients did indeed respond to the medication within 12 weeks. But depending on the medication, between 7.6% and 15.5% responded in weeks 13-48, the median time of response for the “late responders” being 20 weeks, or about 4.5 months.

Studies like this, though preliminary, raise some interesting issues. Dr. Deborah Friedman (from the University of Texas Southwestern Medical Center), quoted in an article in Neurology Today, gives her response to some of the online chatter that’s been happening:

There are colleagues of mine who said anybody who would keep somebody on a medication that didn’t work longer than three months, it’s unethical. Well, I keep my patients on it for four to six months and that’s what we did with Botox, because I’ve seen people respond late.

Dr. Deborah Friedman

Unethical? Why unethical?

Think about it. Even if there are a few people who may respond late, your chances of responding to the medication do significantly drop after 12 weeks. So if every patient is now put on a trial of 20 weeks or more (some are suggesting 6 months to a year), the drug company selling the product certainly benefits. The insurance company may not be so sure. And most of the people taking the medication for those extra weeks will never benefit from it, and so are only dealing with any side effects with no benefit at all. That’s the cold number crunching.

But the fact remains that some patients may be missing out because they’re only trying the medication for 12 weeks.

All right then, is there a way we could identify those patients – the ones that will benefit eventually – thus improving the odds?

The study has perhaps started to point the way. The researchers did note some tendencies among the late responders:

  • More likely to have a higher average body mass index
  • Slightly less likely to have one-sided pain with allodynia (more on this below)

Of course, this works both ways. If you have one-sided pain with allodynia, you may be a little more likely to benefit from an anti-CGRP preventative. Because basically the late responders were simply a little more like the non-responders.

This is a long way from a way to identify which patients will respond late. But what the study does tell us is that we should be looking closer to find out how we can identify those patients – it shows us that there may be a way, eventually.

Right now, it’s probably best to have a good relationship with a specialist you trust, and let them help you decide if it’s worth it to try your medication (or other treatment) for longer. They know you best, and know your medical history.

To delve further into this topic, check out the article at Neurology Today by Thomas R. Collins: Late Migraine Responses Seen for Anti-CGRP Therapy

Also the National Headache Foundation has put out a video on the optimistic side, explaining this study:

Large International Migraine Genetic Study

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Last month a report was published on a large international genetic study that is giving us more clues in the world of migraine genetics.

DNA puzzle

The study, published in Nature Genetics, included 102,084 migraine cases and 771,257 controls. 123 “loci” were identified – that is, the locations on a chromosome, that seem to be connected with either migraine or migraine with aura. Here are a few of the findings:

  • 123 loci is a big increase from what we knew before. 86 were previously unidentified.
  • The study did specifically split up two main migraine types – with and without aura. And there does seem to be a difference. Some genetics risks seem to be specific to one or the other. That not only means a biological difference, but possible future specific treatments.
  • Researchers found new evidence for treatments we already have – CGRP related drugs. In their words, “Our findings also include new risk loci containing target genes of recent migraine drugs acting on the CGRP pathway and the serotonin 5-HT1F receptor.”
  • The new study confirms again that migraine is “polygenic”. That is, it probably arises from multiple causes.
  • The loci especially related to the central nervous system (CNS) and the vascular system. That provides further confirmation that migraine is a neurovascular disease – that is, related both to the neurological system and blood vessels.
  • Although not as strong as the CNS and vascular connections, the study also found some connection to the digestive system and ovary tissue, suggesting a possible connection with these systems as well.

As mentioned above, this type of research not only helps us better understand migraine, it may also lead to genetic testing, better treatments, and even migraine-type specific treatments. But as the researchers note, although our study of genetics has come a long way, it still has a long way to go.

You can read the technical details and discussion from the researchers here: Genome-wide analysis of 102,084 migraine cases identifies 123 risk loci and subtype-specific risk alleles

For a good summary of the study, check out ScienceDaily: Largest genetic study of migraine to date reveals new genetic risk factors

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The articles on Headache and Migraine News are © 2004-2024 J. Cottrill.
Every effort is made to ensure the accuracy of each article, and to point you to further sources of information. However, this site is for informational purposes only and should never replace a visit to your doctor.