PO-41 | Eptinezumab for difficult-to-treat migraine: who responds and who needs more

Alessandro Visentini,^1,2,3 Roberta Messina,^1,2,3 Ilaria Cetta,^1,2,3 Edorardo Ratto,¹ Laura Zanandrea,^1,3 Federica Genovese,^1,2,3 Irene Chinali,¹ Bruno Colombo,¹ Massimo Filippi^1,2,3 | ¹Neurology Unit and ²Neuroimaging Research Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; ³Vita-Salute San Raffaele University, Milan, Italy

Background: Eptinezumab is a monoclonal antibody (mAb) targeting the CGRP recently approved for migraine prevention. This study aimed to assess the rates of responders and super-responders to eptinezumab, and to identify clinical predictors of treatment response and dose escalation over a 9-month period.

Methods: Fifty-eight adult patients with migraine, attending the Headache Clinic at San Raffaele Hospital (Milan), were enrolled. Demographic data and clinical parameters, including monthly headache (MHD) and migraine (MMD) days, acute medication use in terms of pills (AMP) and days (AMD), headache intensity (NRS), disability (MIDAS), impact (HIT-6), and allodynia symptoms (ASC-12) scores, were recorded at baseline and after 3 (M3), 6 (M6), and 9 (M9) months of treatment. Adverse events were assessed at all time-points. Responders and super-responders were defined by a ≥50% or ≥75% reduction in MMD from baseline, respectively. All patients initially received 100 mg of intravenous eptinezumab; for those with a suboptimal response based on the clinician’s judgment, the dose was escalated to 300 at M3 or M6.

Results: The cohort was predominantly female (92%), with a median age of 50 years (IQR 36–56). Chronic migraine was present in 76% of patients. Participants had failed a median of five prior preventives (IQR 3–6) and 47% had prior anti-CGRP mAb exposure. The median MHD e MMD values at baseline were 20 and 16 respectively. At M3, responders were 40%, including 21% super-responders. At M6 responders were 23%, including 5% super-responders. At M9 responders were 46%, including 17% super-responders. A significant predictor of non-response to treatment at M3 was prior therapy with mAb (p = 0.0137). Patients who increased the eptinezumab dosage to 300mg were 72% at M3 and 87% at M6. Factors associated with dose escalation included higher MHD and MMD at baseline (p<0.05), and a prior failure to anti-CGRP mAb (p < 0.04). Only two patients reported mild adverse events.

Conclusion: Eptinezumab is effective and well-tolerated in patients with high-frequency and treatment-refractory migraine. Prior anti-CGRP mAb failure and higher baseline migraine burden predict the need for early dose escalation. Initiating therapy at 300 mg may be advantageous in selected difficult-to-treat cases.