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

Abstract

BackgroundHeadache 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 seriesWe report a series of seven patients in whom headaches were the presenting feature of IIH the headaches had migraine-like characteristics, as is typical in many IIH patients. Papilledema 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.ConclusionsThose 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.

Understanding the link between obesity and headache- with focus on migraine and idiopathic intracranial hypertension

“…with persistent headache [42]. Furthermore, erenumab has been demonstrated to treat headache in active IIH, while raised ICP and papilledema remain [43]. However, given the open label, non-controlled nature of these studies, further investigation is required.…”

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

“…Clinical examination confirmed no cranial nerve palsies and slit‐lamp examination confirmed no ongoing papilledema. Mean (SD) peripapillary retinal nerve fiber layer thickness at baseline was 98 (17.8) µm for right eyes and 100 (20.9) µm for left eyes, as quantified by OCT. During the 12‐month follow‐up, seven patients experienced weight gain and recurrence of papilledema, details of these cases are reported separately 39 but they remain in the overall analysis to reduce bias from loss to follow‐up.…”

“…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 treated with erenumab. We have reported these patients individually as a case series 39 …”

“…During this study, patients were not on a formal weight management program; however, we anticipate that all would have been aware of the importance of weight management in maintaining their IIH in ocular remission. 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.…”

Intracranial Pressure Directly Predicts Headache Morbidity in Idiopathic Intracranial Hypertension

“…Calcitonin gene related peptide (CGRP) monoclonal antibodies have been noted in a prospective study to signi cantly improve headache in patients with IIH and persistent post-IIH headache (resolved papilloedema), suggesting CGRP may modulate headache pain. 13,14 The relationship between development of headache and raised ICP in IIH is poorly understood. A previous trial in 165 patients with newly diagnosed IIH 15 did not identify an association between intracranial pressure and headache.…”