The Consumer’s Guide to CGRP Medications for Chronic Migraine

Before CGRPs hit the market, the only medications prescribed to prevent migraine were drugs that had originally been developed to treat other conditions, such as high blood pressure, epilepsy, or depression, says Dr. Goadsby. Researchers noticed these drugs seemed to help migraine and studied them for that, but when it came to adding them to the migraine disease arsenal, “We got there by accident, so we never really knew how they worked — and still don’t,” he says.

By contrast, CGRP antagonists were developed specifically for migraine, based on an understanding of the role CGRP peptides play in the disease.

Four of each type are approved by the FDA, with the promise of more coming down the pike.

CGRP monoclonal antibodies, which prevent migraine:

• eptinezumab (Vyepti)
• erenumab (Aimovig)
• fremanezumab (Ajovy)
• galcanezumab (Emgality)

CGRP receptor antagonists (called gepants), which help prevent and relieve migraine:

• atogepant (Qulipta)
• rimegepant (Nurtec)
• ubrogepant (Ubrelvy)
• zavegepant (Zavzpret)

This is a plus if you and your doctor decide you could benefit from trying a CGRP, because you’ll likely have options for how to take it and the flexibility to try something different if your original choice doesn’t work for you.

Orally (one tablet per day):

• atogepant (Qulipta)
• rimegepant (Nurtec)
• ubrogepant (Ubrelvy)

By injection (once a month):

• erenumab (Aimovig)
• fremanezumab (Ajovy)
• galcanezumab (Emgality)

By infusion (once every three months):

• eptinezumab (Vyepti)

As a nasal spray (once a day):

• zavegepant (Zavzpret)

CGRP medications for migraine have been found to have a trio of key benefits, research has found. Namely, they’ve been shown to reduce:

• Migraine frequency (the number of attacks that occur per month)
• Headache days (the number of days that an attack lasts the entire day)
• The need for migraine attack treatment

But that’s not all. “Migraine is a complex neurological disorder with many manifestations. Pain is one of them, but so are light or sound sensitivity, cognitive thinking dysfunction, brain fog, a dreadful sense of fatigue, and a sense of being sleepy,” notes Goadsby. “So, when we say CGRPs are effective, they don’t just reduce the pain days and severity; they also reduce all of those other symptoms.”

CGRP drugs are well tolerated, says Yacoub, especially compared with other migraine treatments. “The older medicines are more side-effect prone,” Goadsby adds.

Research shows a substantial number of people who have migraine disease either don’t respond to other treatments or can’t tolerate them. But a study published in The Lancet found that participants who took an erenumab CGRP or a placebo had a roughly equal reaction.

A review published in 2023 in the Saudi Journal of Medicine and Medical Sciences reported the most common side effects as nausea, upper respiratory tract infection, constipation, fatigue, and mild skin reactions at the injection site. And only a small percentage of people who take CGRPs appear to experience side effects, based on the FDA Adverse Event Reporting System.

If you do experience side effects from a CGRP migraine drug, the benefits are likely to outweigh the risks. And there are steps you can take to help mitigate mild side effects, such as constipation, which is especially common.

In that case, “You can change your diet. You can change your exercise habits,” suggests Goadsby. Or, if you have a reaction at the injection site, a warm compress or anti-itch medication could relieve it.

Most people who try a CGRP medication for migraine notice an improvement within the first month of starting the drug. That said, it may take three months, or sometimes more, to get the full benefit — meaning very few migraine attacks or even none at all.

“If you get a response straightaway, congratulations,” says Goadsby. “But if you don’t, being patient will be rewarded. I advise people to at least [stick with it] for three months, but the data suggests that you’re really better off [going] four or five months to be absolutely sure.”