Real-world comparison of treatments with antibodies targeting the CGRP pathway or botulinum toxin type A for resistant migraine.

[BACKGROUND] Migraine, particularly in its chronic and treatment-resistant forms, imposes a significant burden on patients. Monoclonal antibodies targeting the calcitonin gene-related peptide (CGRP) pathway (anti-CGRP mAbs) and onabotulinum toxin type A (BTX-A) have emerged as key preventive treatments for resistant migraine. However, direct comparisons between these therapies remain limited.

[OBJECTIVES] This study aimed to compare the effectiveness of anti-CGRP mAbs and BTX-A in patients with resistant migraine in a real-world setting at a single tertiary care center in France.

[METHODS] A retrospective cohort study was conducted, including 93 patients treated with either anti-CGRP mAbs (n=50) or BTX-A (n=43) for six months. Propensity score matching and inverse probability of treatment weighting (IPTW) were applied to balance baseline differences between groups. The primary outcome was the proportion of patients achieving a ≥50% reduction in monthly headache days.

[RESULTS] After six months, 43% of patients in the anti-CGRP mAbs group and 18% in the BTX-A group achieved a ≥50% reduction in monthly headache days (P=0.003). Using a less stringent 30% threshold, response rates were 54% for anti-CGRP mAbs and 36% for BTX-A (P=0.06). Similar results were observed when the analysis was restricted to chronic migraine patients (n=79). The reduction in monthly headache days was significantly greater in the anti-CGRP mAbs group at both three months (P=0.015) and six months (P=0.022).

[CONCLUSION] Anti-CGRP mAbs demonstrated superior efficacy compared to BTX-A in resistant migraine patients.