Human monoclonal antibodies are far too large a molecule to cross the blood brain barrier and appear to work by blocking the inflammatory response process around the meningeal vessels. They thus do not alter the fundamental brain networking pathophysiology, and indeed I have heard reports from other clinicians that the other symptoms can remain but the headache goes

My own thoughts on this are that this may result in a changed classification system moving away from the purely descriptive IHS to one that includes the cause. At the moment there is a somewhat arbitrary distinction between episodic and chronic migraine at 15 days a month but to my mind there is a pathophysiology distinction between a primarily central process which results in a chain reaction that includes pain from inflammatory processes in the meninges but fully resolves, and a primarily inflammatory process that extends beyond the central cyclical processes to that results in some form of chronic inflammatory process in the meninges (and possibly astrocytes within the brain)

I believe that what is presently called chronic migraine is in fact a cyclical process where the attacks are so frequent that one attack has not yet finished before the next one starts, and the episodic element had been submerged by the frequency of attacks, and that this is fundamentally different to a true chronic daily headache that is unremitting and unchanging

MABs such as Erenumab are incredibly expensive and government funding for it in the UK has just been rejected in favour of Botox but I can see that there may be a place for it in the future in some types of truly chronic headaches where Botox has not worked

The other new treatment to consider is Daith Ear Piercing. It passes through the area innervated by the auricular branch of the vagus nerve (ABVN). Vagus nerve stimulation is an established treatment for migraines and epilepsy

Like any other treatment, daith piercing is not effective for all sufferers, but our clinical experiences are that it can be extremely effective in about 50% of patients (including those who have failed other therapies) with about 10% reporting complete cessation of their migraines for extended periods

Once scientists identified this target molecule, they began trying to develop ways to stop it from being activated at the start of migraines, as a kind of abortive treatment. An agonist makes a molecule work more efficiently, and an antagonist blocks or reduces the molecule’s effect. The CGRP antagonist did work to decrease migraine pain based on certain measures, but there were some serious side effects including liver toxicity.

You have likely seen ads for monoclonal antibody (mAb) cancer and autoimmune therapies. There are lots of different types of mAbs, and while some harness a person’s own immune system to block replication of cancer cells, others stop a reaction in the body by binding to a target molecule or receptor and inhibiting it, thus preventing the reaction from continuing. The CGRP mAbs have this effect, and because they have a long duration of action (called a half-life), they can be administered much less frequently than typical migraine medications that are taken daily (with the exception of botulinum toxin, which is injected every 90 days). These new migraine medications are injected under the skin monthly, and have thus far demonstrated a statistically significant decrease in days of migraine. Four different drug companies are developing these new molecules, with two versions already sent to the FDA for approval.

If you think you may be a candidate for this new type of migraine medication, talk with your doctor, and perhaps ask for a consult with a neurologist or headache specialist who can help you understand more about the medication. Monoclonal antibody therapy is expensive, and there will likely be regulations about for whom s the treatments are appropriate. Much more research needs to be done about who is the best candidate for this therapy. But for many migraine patients who have not responded to the standard treatments, or who have had intolerable side effects such as cognitive dysfunction, low blood pressure, weight loss or gain, or other issues, CGRP monoclonal antibodies are safe and well tolerated, and are an exciting new development for migraine therapies.

Thank You for all Your's point of view. Chris Blatchley view of chronic migraine as "a cyclical process where the attacks are so frequent that one attack has not yet finished before the next one starts " is attractive. I agree with Daniel Cebo that CGRP Abs may be alternative for many migraine patients who have not responded to the standard treatments. The cost of treatment is huge. In Poland we also doesn't have any government funding for this treatment.