Practical NeurologyImproving Beyond Fewer Headache Days: Redefining Success in Migraine Treatment

American Headache Society now recommends CGRP-targeting therapies as first-line migraine prevention without requiring prior treatment failures, representing paradigm shift from last-resort positioning. VYEPTI (eptinezumab-jjmr) is IV CGRP therapy administered four times yearly, shown to reduce monthly migraine days in phase 3 trials.

🎯 CLINICAL CONSIDERATIONS

• PROMISE-2 trial showed 39.3% of patients (100 mg dose) achieved ≥75% reduction in migraine days at second dose
• VYEPTI 300 mg reduced acute headache medication use by ≥52% vs. 35% placebo in chronic migraine patients
• AHS defines meaningful improvement as ≥30% MIDAS score reduction (baseline ≥20) or ≥5% reduction (baseline 11-20)
• Most common adverse reactions were nasopharyngitis (6-8%) and hypersensitivity reactions (1-2%); 1.9% discontinued due to adverse events

💊 PRACTICE APPLICATIONS

• Consider CGRP therapies as first-line prevention per updated AHS position statement
• Use MIDAS questionnaire to measure treatment response and functional impact over three months
• Monitor for hypersensitivity reactions, hypertension, and Raynaud’s phenomenon during IV administration
• Educate patients that 30-minute infusion schedule is quarterly, with 100 mg recommended dose

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