CGRP Preventives

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What is CGRP (calcitonin gene related protein)?

CGRP is a neuropeptide.  Many people are familiar with the term neurotransmitter.  A neurotransmitter is released from one neuron and binds to a receptor on a 2nd neuron.  Neuropeptides do this but their receptors are also found on non-neurons.  In the case of CGRP receptors in the brain, they are found on microglia and on blood vessels.  There are CGRP receptors all over the body.  Because CGRP is so widespread in the human body, it is surprising to Dr. Loftus that there are not more side effects from these medications that are so useful to treat migraine.
CGRP has been demonstrated to be elevated during migraine headaches (and cluster headaches).  Once the headache resolves, the level drops.  IV infusion of CGRP can trigger headaches in migraine patients.  For this reason, CGRP has been targeted for both acute migraine treatment and migraine prevention.
Monoclonal antibodies are antibodies that have been designed for a specific target.  The part of the antibody that determines the target is referred to as the warhead.  Monoclonal antibodies are now used in dozen of diseases.  They are not metabolized by the liver or kidney.  Other than local skin reactions if they are injected and the possibility of the development of an allergy, the monoclonal antibodies are essentially side effect free outside of their effects on the target.  In the case of migraine, monoclonal antibodies can target either CGRP itself (attacking the key) or target CGRP receptor (attacking the lock).

Aimovig®

Aimovig is a monoclonal antibody that targets the CGRP receptor.  It was the first CGRP related migraine agent approved by the FDA (May 2018).  There are two doses, 70 mg and 140 mg on the market.  The drug is given monthly.  The primary side effect of targeting the CGRP receptor appears to be slowing of the GI tract.  Slowing the GI track can cause constipation is it raises the pressure inside the gut.  For this reason, Dr. Loftus avoids this medication in patients with known gut issues such as ulcer and Chrohn’s disease.  More controversial is if Aimovig causes hypertension in some patients.  The FDA added a warning that it does based upon post marketing reports but the controlled data did not show an increase in blood pressure compared to the placebo arm of the study.

Ajovy®

Ajovy is a monoclonal antibody that targets the CGRP neuropeptide itself.  If was the first of three monoclonal antibodies targeting CGRP approved by the FDA (September 2018) and the first time the drug was presented to physicians post approval was at the Southern Headache Society conference in 2018.  It was not found to cause constipation.  The drug was proven to work in chronic migraine given 3 shots every 3 months.  In episodic migraine the dose proven to work was one shot per month or three shots given every 3 months.  For chronic migraine, 1 shot each month was never tested for prevention.  Despite this, 1 shot per month is the most common dosing schedule used for Ajovy for chronic migraine.

Emgality®

Emgality is a monoclonal antibody that targets the CGRP neuropeptide and was the 2nd drug of this type that was FDA approved to prevent migraine headaches.  The dosing of this medication for migraine is 2 – 120 mg shots to start treatment and then 1 shot each month.  The same dose is used for both chronic migraine and episodic migraine.

Vyepti®

Vyepti is a monoclonal antibody that targets the CGRP neuropeptide and was the 3rd drug of this type approved by the FDA.  It is given intravenously to patients every 3 months.  Two doses are approved, both 100 mg every 3 months and 300 mg every 3 months.  Because it is intravenous, it is not associated with any local shot reaction.

Nurtec®

Nurtec is an oral CGRP receptor blocker that was FDA approved to treat acute migraine when it was approved for use as a migraine preventative.  It therefore because the only drug ever approved for both acute migraine treatment and migraine prevention.  For prevention, it is given every other day.  Like Aimovig®, it is associated with constipation but the constipation rate is lower than Aimovig® presumably because it is given every other day.  This drug works best for constipation when patients have another acute medication to take for headaches that occur on days that Nurtec is not scheduled to be taken.

Qulipta®

Qulipta is an oral CGRP receptor blocker that has been demonstrated to prevent migraine in both episodic migraine and chronic migraine. It comes in 3 doses, 10 mg, 30 mg, and 60 mg.  The lowest dose is really designed so one can use it if the patient is on a drug that slows the metabolism of the medication.  30 mg and 60 mg are the more commonly used doses for migraine prevention.  Constipation is the primary negative side effect.

 

 

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five star patient reviews dr loftus
Five star patient reviews

Neel S.(Patient Since 2015)

Dr Loftus does more than practice medicine. He heals and cares for his patients, and makes sure that they are ok. He is a remarkable medical doctor, with the courage to explain his medicine to his patients , and his staff are very kind. They have always responded and helped me. I just wish dr Loftus had been my neurologist many years ago- but so glad he is my doctor now.

Margaret D.(Patient Since 2021)

Thank God for Dr. Loftus! For the first time in my life I developed a Status Migraine which in general are resistant to the usual pain meds and typically send people straight to the ER. Dr. Loftus came with high praise from family members who are longtime patients of his and who travel from out of town and even out of the country for their appointments with him. Thankfully, I was able to schedule an emergency appointment. Not only did Dr. Loftus treat me as though I had been one of his patients for years, he also worked tirelessly to make me pain free, often times checking on my pain level on the weekend. Fortunately he was also able to keep me out of the ER by treating me directly in his office. When I shared with my internist all of Dr. Loftus’ very thorough medical notes, he assured me that I would be hard pressed to find the care and treatment I received with in an office setting, especially in such an immediate manner. He also assured me that Dr. Loftus was clearly very skilled, very smart and extremely dedicated to helping his patients find the appropriate treatments for the specialized care of migraines. I feel grateful every day to Dr. Loftus to be able to say that I am now on the road to a speedy recovery from this difficult experience and well on my way to getting back to a pain-free life. Thank you Dr. Loftus — you and your team raise the bar for extraordinary patient care. I take comfort in knowing that I now have you for a doctor.

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Dr. Brian Loftus, MD square profile picture

Providing headache and hyperhidrosis care & wellness for over 25 years.

Dr. Brian Loftus, M.D.

Dr. Loftus is Board Certified in Headache Medicine as well as Neurology. In private practice since 1994, Dr. Loftus’ practice has gotten busier and he has decided to concentrate his practice in areas that he can make a particular difference compared to other neurologist. Therefore, Dr. Loftus has chosen to focus his neurology practice on headaches & head pain, headaches during pregnancy, and hyperhidrosis. In the spring of 2006, Dr. Loftus relocated his practice from the Texas Medical Center to Bellaire, just 5 miles west. He has been named a Texas Monthly “Super Doctor” and an H Texas magazine “Top Doctor” multiple times.

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