CGRP-Targeted Treatments in Ottawa

• Some people notice improvement within weeks

• Some CGRP antibodies have shown benefit in hours (i.e., eptinezumab - Vyepti ®)

• For others, benefit builds gradually

• A fair trial usually requires 3-6 months

• Full benefit may take 12 months

• Improvement may begin within days to weeks

• A meaningful trial requires 8–12 weeks

If CGRP monoclonal antibodies or gepants are effective:

• Treatment is continued

• There is no monitoring required

• Many patients can transition prescription renewal to their family physician

• Treatment may be discontinued 1-2 years later to revaluate whether it needs to be continued

CGRP monoclonal antibodies are generally well tolerated.

Possible side effects include:

• Injection-site reactions (redness, soreness)

• Constipation

• Muscle or joint aches (uncommon)

• Fatigue (uncommon)

• Urinary tract infections or nasopharyngitis (rare)

Serious side effects are rare.

No.
These medications:

• Do not suppress the immune system

• Do not increase infection risk

• Are not considered immunosuppressive therapies

Gepants are generally well tolerated.

Possible side effects include:

• Constipation

• Weight-loss

• Fatigue

Serious side effects are rare.

CGRP monoclonal antibodies are not recommended during pregnancy due to limited safety data.

If pregnancy is planned:

• These medications should be stopped at least 6 months before pregnancy

This allows time for the medication to fully clear from the body.

If you are pregnant or planning pregnancy, we will help you find alternative migraine strategies.

Gepants are not recommended during pregnancy due to limited safety data.

If pregnancy is planned:

• These medications should be stopped at least 1 week before pregnancy

This allows time for the medication to fully clear from the body.

If you are pregnant or planning pregnancy, we will help you find alternative migraine strategies.

Data on breastfeeding are limited but growing, and expert consensus is that CGRP monoclonal antibodies' expression in breast-milk is low, the amount of drug an infant may consume and ultimately absorb is trivial. Decisions are individualized based on:

• Migraine severity

• Available alternatives

• Patient preferences

We help guide these discussions using the best available evidence.

Data on gepant use and breastfeeding are limited but growing. Small case series suggest the amount of gepants in breastmilk is small.

We help guide the discussion around gepant-use during breastfeeding and lactation to help you make an informed decision.

In Ontario, coverage for CGRP monoclonal antibodies and atogepant (Qulipta ®) often requires:

• A diagnosis of episodic or chronic migraine

• Documentation of migraine frequency

• Trials of at least two oral preventive medications at therapeutic doses (usually for ~3 months each, depending on insurer)

People without private insurance may be eligible to have the cost of CGRP antagonists reimbursed through an application to the Exceptional Access Program (this can be done by any doctor).

We assist with:

• Insurance forms

• Prior authorization

From a medical perspective, CGRP monoclonal antibodies and gepants can be used:

• Alone

• Alongside other oral preventive medications

• Concurrently with Botox ® for chronic migraine, although insurers will typically not cover both

Insurance plans may restrict coverage of combination advanced therapies.

From a medical perspective, it is safe to combine CGRP monoclonal antibodies and gepants although the combination may increase the risk of constipation.

Insurance plans may restrict coverage of combining a preventive gepant - like atogepant (Qulipta ®) and CGRP monoclonal antibodies..