CGRP-Targeting Therapies as a First-Line Option for Migraine Prevention
The American Headache Society's 2023 position statement on CGRP-targeting therapies continues to shape migraine care and treatment standards. The updated position statement, led by Dr. Andrew Charles, marked a significant shift in migraine prevention by formally positioning CGRP-targeting therapies as first-line options instead of last-resort interventions.
As Dr. Charles explained in his interview with Dr. Rashmi Halker Singh, the overwhelming evidence for the efficacy and tolerability of CGRP-targeting therapies, supported by growing clinical experience, prompted the AHS Board of Directors to update its prior guidance. He emphasized that the effort was rooted in the American Headache Society’s mission to improve the lives of people with headache disorders, noting that it was “made possible by this surge in evidence and also a surge in clinical experience over that time window, which has really been astonishing.”
Watch the full interview with Dr. Andrew Charles, MD:
The AHS Board of Directors released this focused statement in response to more than 150 new clinical and real-world studies supporting the safety, efficacy, and adherence of CGRP-targeting therapies. This evidence-driven update signaled a clear evolution from step care to first-line care, encouraging clinicians to consider CGRP-targeting therapies early in treatment planning.
Dr. Charles clarified, “We’re not advocating that these are the first-line therapies, they are a first-line option… there shouldn’t be a requirement that patients try other therapies first before trying CGRP-targeting therapies.” This nuance reflects a growing recognition that earlier access to these treatments can improve outcomes for many patients while supporting individualized decision-making between providers and patients.
Beyond medication cost, the position statement urges clinicians to evaluate the broader burden of migraine, lost productivity, reduced quality of life, and healthcare utilization when developing preventive strategies. “We hope this will expand the opportunities for patients to have access to these therapies,” Dr. Charles added, underscoring the update’s goal of improving care access across diverse patient populations.
This position statement marked an important moment in migraine care, validating the growing body of evidence supporting CGRP-targeting therapies and their role in improving patient outcomes. It also underscored the value of incorporating real-world data into clinical recommendations, bridging the gap between research and practice to guide more effective, patient-centered care.
Clinicians were encouraged to revisit the latest AHS guidelines and consensus statements to align care with current recommendations and emerging therapeutic options.
Read the Interview Transcript:
Dr. Rashmi Halker Singh:
I am Rashmi Halker Singh. I'm the Deputy Editor of Headache. I'm joined today by the current president of the American Headache Society and the recent first author of a publication entitled Calcitonin Gene Related Peptide, CGRP. Targeting Therapies are First Line Option for the Prevention of Migraine and American Headache Society Position Statement Update. Welcome Dr. Charles, it's so nice to speak to you.
Dr. Andrew Charles, MD:
Thanks very much. I'm excited to be here with you Rashmi.
Dr. Rashmi Halker Singh:
So this is really exciting. The last time we had a consensus statement published by the board of directors was in 2021 where we spoke about how to use these new therapies in migraine care. 2021 wasn't that long ago, so why the need to publish this paper now, right now?
Dr. Andrew Charles, MD:
Yeah. Well, it actually kind of starts I think with the mission of the American Headache Society, which is to improve the lives of people with headache disorders, and that's really sort of the driving reason for doing this, but it's also made possible by just this surge in evidence and also a surge in clinical experience over that time window, which has really been astonishing and it has changed our approach to treating patients in a way that we really thought it was important to update the consensus statement. Also, we've had a lot of input from our members that the consensus statement was needed to be updated with this focused update. I think one other thing just to say quickly is that the previous consensus statements were really broad and dealt with a variety of different treatment approaches, and as a result those are very time consuming and hard to develop. Whereas this one is focused on CGRP targeting therapies and by focusing it allows us to kind of roll things out much more efficiently and in a way that will practically address important problems that we're facing in our clinic every day.
Dr. Rashmi Halker Singh:
Absolutely. I mean, I'm a clinician, as you know. I see patients all the time and these are things that come up in my practice as well. I think the title is quite self-explanatory now. We should not be thinking about step therapy rather when we see someone who has migraine. We should think about these new options as first line and put them as an option to the patient. But what else is in the update that you think is important that a clinician should be aware of?
Dr. Andrew Charles, MD:
Yeah, well I think it's kind of what you alluded to conceptually is that this is really a viable option that we should think about as first line. And in the past, this kind of step therapy approach was appropriate because these were newer therapies that we didn't have as much clinical experience with and they're more expensive. And so it was reasonable to suggest trying other therapies first. But now again, as I just alluded to, the evidence for their efficacy and especially their tolerability is just so overwhelming and our clinical experience backs that up. It was sort of going through the literature in preparation of this manuscript, and if you type in real world evidence, CGRP, migraine prevention, there's something like 150 papers within the last two years on this and they're coming from all over the world, which is great.
One of the kinds of interesting things about this is that we think about quality of evidence being with the high quality of evidence, really being either a randomized placebo controlled clinical trials or head-to-head trials. But when you start to see these real world studies, they have their own value, especially with issues like tolerability and adherence over time where you get to really see if people who start on these therapies stay on them. And that's something that is really compelling about the evidence that these sort of non-traditional endpoints like adherence to therapies are ones that are really supporting the use of these approaches. The other things I guess I would point out are what comes out of some of the formal clinical trials and also some of the real world evidence is that the therapies work even in patients who've tried a host of other preventive therapies and failed them either due to lack of efficacy or tolerability.
So that's a very important point. The other point is that these therapies are approved now, most of them for both episodic and chronic migraine. And so that's something that is a takeaway from the study that really supports the use of these therapies. And finally, I think one of these things that this study brings forward, or I should say the consensus statement brings forward is cost other than the cost of the medication. So costs in terms of healthcare utilization costs, in terms of acute medication use, and then cost to the patient, personal costs, loss of work productivity, loss of quality of life. And these are costs that we often haven't really factored in in terms of decision making about therapies, but it really behooves us to do that given the evidence supporting these CGRP targeted therapies.
Dr. Rashmi Halker Singh:
Absolutely. I think this really validates the experience an individual who has migraine has just because cost is so much more than the amount you're paying for the medication, it's the time lost, it's your productivity lost, it's how much time you're spending accessing healthcare and everything else. And I think it was really beautiful to see all that outlined and also allows a clinician to really advocate for their patient in the best possible way because now we have drugs that are designed to treat the condition being elevated to first line therapy, and I think that's really nice. Conversely, from the patient perspective, as we think about our patients who are thinking about the gaps in their healthcare, what are your hopes for this paper? What do you hope this consensus statement will do as we think about it from that standpoint?
Dr. Andrew Charles, MD:
Yeah. Well, so the previous consensus statements, because of the evidence that they were based upon and the experience that we had at the time we're really suggesting that step care was okay. Now we're saying that, and to be clear, we're not advocating that these are the first line therapies. They are a first line option, and so certainly patients and providers can consider other approaches, but just to have these on the list of the first line and to suggest that there shouldn't be a requirement that they try other therapies first before trying CGRP targeting therapies is something that we hope will expand the opportunities for patients to have access to these therapies. Now, it's not clear that that's going to happen. I mean the payers are not necessarily going to go along with this statement, but at least it clears the way where we're not actually saying as a society that this is step care should be the way to go. We're basically taking that out of the statements such that going straight to these therapies is something that is potentially recommended. It's not, again, always the approach, but it's an approach that is a reasonable one for selected patients.
Dr. Rashmi Halker Singh:
Absolutely. I mean, I think this just allows us to be more holistic in our approach to migraine care because for some people the older medications may be the best option and for some people it might be one of these newer options, but at least now we can have that conversation and we can think about of these on the table at the same time. Alright, well, do you have any additional questions or sorry comments that you'd like to share with us?
Dr. Andrew Charles, MD:
No, I mean I would close by saying that these are just very exciting times for headache medicine, as you know, and we as a society and the Headache Journal is really trying to highlight all the advances and the new opportunities for patients. So thanks very much for having me on and allowing me to talk about this paper.
Dr. Rashmi Halker Singh:
Well, thank you so much for your hard work on this paper and everything else you do for the Society people live with migraine. Thanks for talking to you today.
Dr. Andrew Charles, MD:
Sure, my pleasure. Great talking to you.