Calcitonin gene related peptide monoclonal antibody treats headache in patients with active idiopathic intracranial hypertension

Abstract

Background Headache is the dominant factor for quality of life related disability in idiopathic intracranial hypertension (IIH) and typically has migraine-like characteristics. There are currently no evidence-based therapeutics for headache in IIH, and consequently this is an important unmet clinical need. Case series We report a series of seven patients in whom headaches were the presenting feature of IIH and the headaches had migraine-like characteristics, as is typical in many IIH patients. Papilloedema settled (ocular remission) but headaches continued. These headaches responded markedly to erenumab, a monoclonal antibody targeted against the calcitonin gene related peptide (CGRP) receptor. Of note, there was a recurrence of raised ICP, as evidenced by a return of the papilloedema, however the headaches did not recur whilst treated with erenumab. Conclusions Those with prior IIH who have their headaches successfully treated with CGRP therapy, should remain under close ocular surveillance (particularly when weight gain is evident) as papilloedema can re-occur in the absence of headache. These cases may suggest that CGRP could be a mechanistic driver for headache in patients with active IIH.

The Role of Metabolism in Migraine Pathophysiology and Susceptibility

“…This study brought new insights to the association of CGRP in IIH headache. Seven of the patients had a recurrence of their raised intracranial pressure (evidenced by papilloedema), yet no return of their headache, suggesting CGRP may have a role in headache attributed to IIH [ 33 ]. Similarly, CGRP was found to induce headache exacerbation with migraine-like features in patients with persistent post-traumatic headache attributed to mild traumatic brain injury in a recent randomized control trial [ 34 ].…”

Erenumab for headaches in idiopathic intracranial hypertension: A prospective open‐label evaluation

“…As the majority of follow-up visits were by phone, weight was not formally assessed, but in those describing weight gain we formally assessed for recurrence of papilledema. 39 We cannot exclude the possibility that weight loss could have occurred in these patients during follow-up. However, the above are unlikely to be the principal factors explaining our results as the cohort at baseline were experiencing a consistently high headache load, with similar MmsHD Furthermore, a limitation of this study was that non-responders were not followed up and this could have inflated the outcomes.…”

“…As the majority of follow-up visits were by phone, weight was not formally assessed, but in those describing weight gain we formally assessed for recurrence of papilledema. 39 We cannot ex- Furthermore, a limitation of this study was that non-responders were not followed up and this could have inflated the outcomes. However very low numbers of patients were lost to follow-up by 12 months (five ineffective, one pregnant, and one noncompliant).…”

“…Seven patients from our cohort suffered recurrence of raised ICP, as evidenced by a return of the papilledema, however, the headaches did not recur while treatedwith erenumab. We have reported these patients individually as a case series 39.…”

Current Perspectives on Idiopathic Intracranial Hypertension without Papilloedema

“…Indeed, discoveries of therapies for headache attributable to IIH also require systematic evaluation, as there is only one open label study investigating use of a calcitonin gene related peptide monoclonal antibody to treat headache in patients with active IIH [ 76 ]. What was interesting was that a small subset of patients had reoccurrence of their papilloedema without a return of their headache symptoms, which may implicate CGRP in the underlying pathways causing headache [ 77 ]. Likewise, the role of weight management requires further exploration as obesity is a consistent risk factor in the majority of IIHWOP case series, and for IIH this is a modifiable risk factor [ 78 ].…”