Is Aimovig a breakthrough drug for migraines? Should migraineurs jump on board, or is there reason to be cautious?

In this episode, Dr. T discusses the pros and cons of this new drug and new class of medications for migraine prevention, along with who it might be a good fit for.

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EPISODE TRANSCRIPT

Howdy fellow beast slayers. So, today’s episode is one that I know some of you have been waiting for. As some of you may know, the first drug, and a new class of migraine medications recently hit the market. This one goes by the name Aimovig. That’s the brand name for the drug Erunemab. And many of you have asked if I would share my thoughts about it.

There’s been a fair amount written about it in the news lately and some excitement and buzz around it. Folks are wondering, if any, role it should have in sort of their overall treatment plan. In this episode I’m gonna be reviewing what I consider to be the pros and cons of this new treatment, and I’ll conclude with how I see this new drug fitting into my own approach as a neurologist and the type of patient I would consider it for.

First, a small bit of housekeeping before we launch into the topic. We just started our latest jump start challenge, which means that our next 30 day challenge is going to be a keto blast, which is our 30 day keto challenge. So, if you want to learn more about that and register, you can go to ketoformigraine.com. And if you start up now, you’ll get the early bird discount.

As a reminder, members of Migraine Neverland have unlimited access to all of our challenges so they can participate in as many of the keto and jump start challenges as they like along with the other challenges that we have just for our Migraine Neverland members. And to learn more about Migraine Neverland, go to mymigrainemiracle.com/endofmigraine.

All right, so, on today’s episode, I’m going to be talking about a new drug that just came out for migraine, which is a part of new class of drugs that are being developed and that have been in development for over a decade now.

And all of these drugs target the calcitonin gene related peptide in some way, and that’s abbreviated CGRP. That’s how I’ll be referring to it in the rest of this episode. There are four drugs that I’m aware of that are being developed or have been developed that target CGRP in some way. One of which is Aimovig, which I believe is the correct pronunciation, although I’m sure there will be many different versions of that.

But Aimovig was just recently approved by the FDA and is now out and available in the market, so you can get it. When it received it’s approval, there was a lot written about it in the news. Most of which was very favorable. Some of which even presented it as a possible miracle drug. This is not that unusual when new drugs hit the market.

You are usually going to get more eyeballs on your news story if it’s sensationalized a little bit. But that being said, there are some reasons for celebration when it comes to this drug, and I’ll be talking about that in a minute.

Before we dig into the topic in depth though, I wanted to read a comment that someone made in our Facebook Migraine Miracle group, which I think really frames this discussion well. So, I’d announced that I was going to be covering this topic and discussing my thoughts about Aimovig, and this was a comment made from of our members, Amy.

She says, “Funny that this drug coming out is what finally spurred me to get on the no drug migraine miracle path. I went to my doctor for a prescription of Aimovig and got one. Send it in, it was incorrect. Called to correct it. Waited for it in the mail. By the time it came, I had finished your book and decided not to fill the prescription. I’m curious to hear your thoughts, but I have decided it is kin to firing my brain’s firefighters. I’m done with any drug manipulating my brain. I no longer want the miracle pill or injection, I’ve found the miracle cure.”

So that was a great post from Amy and I think is a good frame for starting this conversation about Aimovig. So, I’m gonna begin by just giving a little bit of background on the story of this class of drugs and CGRP in particular. CGRP, Calcitonin Gene Related Peptide is, as it says, a peptide, which means it’s shorter in length than a protein. It’s only 37 amino acids long and we know that there are receptors for it that are found throughout the body. Now, we’ve only known that it exists for a little more than 30 years.

And we still don’t know very much about what all it does. Like I said, we know that it’s wide spread, in particular we know that there are receptors for it throughout the body including in these central and peripheral system. But because it’s newly discovered and because it’s so wide spread, that means it probably does a lot and we still don’t know a lot about all those functions.

We do know that it is involved both in increasing the size of blood vessels or what’s known as vasodilation, and in pain signaling during a migraine. In particular, in pain signaling within the trigeminovascular system, which is what’s activated during a migraine and is a source of much of the pain, so this molecule CGRP is involved in that pain signaling.

We know that that peptide is elevated during a migraine, which was kind of the initial impotence for folks looking into this for a possible target for migraine relief or prevention. Since this was discovered that it was part of migraine pathophysiology, there’s been a lot of effort over a decade now towards trying to create a drug that targets the CGRP system in signaling in some way that either leads to fewer migraines or helps relieve migraines.

There’s been a race between several drug companies to be the first ones to bring a drug to market, which is often a big advantage. The first kind of drugs that were developed for this were what is known as CGRP antagonists. These are molecules that work by blocking the receptor for CGRP. The idea is there if during a migraine the CGRP is released to signal pain, if it can’t bind to its receptors, then it can’t ultimately result in the perception of pain.

So blocking a receptor essentially neutralizes it. There were trials done over a decade ago for using this as an abortive, these CGRP antagonists, and while the results were somewhat favorable, the drug resulted in liver toxicity and so, it’s never made it to market because it didn’t pass the safety trials.

So the next approach was to try something different. Either to try antibodies against these CGRP molecule itself, or antibodies against the CGRP receptor.

And Aimovig, which, as I said, is the first in this category of CGRP acting drugs to be approved and the one that recently made headlines because of this, it works in this capacity. It is an antibody against the CGRP receptors. So, instead of blocking receptor, Aimovig is an antibody against the receptor. So the antibody will attach to it, which then provokes the immune system to destroy the receptor, just as the immune system would destroy an invading bacteria that’s been tagged with an antibody.

So now, since the receptor or at least some of the receptors have been destroyed by the immune system, the CGRP doesn’t have anything to bind to, and so you can’t generate as great of a pain signal. The other CGRP drugs that are still in development are antibodies to the CGRP molecule itself. In that case, you’re provoking an immune system to attack the molecule, rather than the receptor for the molecule, but with the hope that the end result is the same.

Now, these type of antibody approaches aren’t well suited to working as an abortive. They’re not well suited to relieving an existing migraine, because it takes time to work. You have to have the antibody attached, the immune system has to remove the receptor, and so on. This new class of drugs has been investigated primarily as a preventative treatment.

And they are all either given subcutaneously, so under the skin by injection, or intravenously, and usually at some type of regular interval around monthly. So, given that this is a novel approach and a new targe for migraines, it’s generated a lot of excitement, and anticipation, and perhaps a bit of hype as well.

What are we as migrainers to make of all of this? Is this a miracle treatment? Should we jump on board? Should we be cautious? To help answer that, I’m gonna divide up the pros and cons as I see it. And I’ll begin with the pros, so the things that I see as favorable aspects of this new drug, this new class of drugs in general, and Aimovig in particular.

So, the first pro is that it does seem to help. Understanding whether or not, or knowing whether or not a drug helps is actually a harder question to answer than you might at first think. That’s largely because the placebo response is significant typically in migraine trials and many pain trials. And so, the typical way to try to eliminate the placebo response is to conduct a study where you have half of the subjects given the actual active drug and half the subjects given a placebo drug. One that’s delivered in the same way, but has no active ingredient in it.

Usually both the subjects in the trial and the people who are administering the trial do not know who’s getting the drug and who’s getting a placebo. And then you look and see if the people getting the active drug do better than people getting the placebo.

The main study for Aimovig was published in November of 2017 in the New England Journal of Medicine. One of the primary metrics that are usually used to evaluate a new migraine drug, a new preventative, is in seeing how many subjects achieve a greater than 50 percent reduction in migraine frequency. If their number of migraines per unit time, usually per month, goes down by more than half.

So, in this study, there are actually one set of subjects who were given a 70 milligram dose of Aimovig and one group who were given 140 milligram dose, and 43 percent of the people who were given the 70 milligram dose had a greater than 50 percent reduction in their migraine frequency, and 50 percent who were given double that, the 140 milligram dose, achieved greater than a 50 percent reduction in migraine frequency.

That sounds pretty good. However, the placebo group response was 26 percent. So 26 percent of the folks in the placebo group achieved greater than 50 percent reduction in their migraine frequency. All in all, the patients who were in this study did improve and a little over half of that improvement was from placebo alone, and just under half of that improvement was from the drug itself, with the higher dose drug achieving a little bit more improvement than the lower dose.

Now, you may wonder how does that stack up against prior preventative treatments? We know that there are several FDA approved medications on the market for migraine prevention. One of the most recently approved is Topamax and very commonly used. In a similar trial of Topamax in 2005 where they looked at the same exact end point, so how many people achieved 50 percent reduction or more in their migraine frequency, 46 percent of people in that trial achieved greater than 50 percent reduction with 23 percent doing so in the placebo arm.

The numbers from the Aimovig trial, and the numbers from Topamax are almost identical. Now, you do have to take any comparison like that that’s not done head to head as part of the same trial with a grain of salt, but we can at least say that it looks to be in the same ball park as the existing treatments in terms of its effectiveness.

Now, I know there are probably some of you listening who may say, “Well, wait a minute. Topamax, I took Topamax and it didn’t work at all for me.” And, this is often a thing that happens, is that we see results that come in a clinical trial that don’t match what actually happens in the real world and there may be several reasons why that is, I could speculate, but I’ll leave that for another day.

But, just taking the data on face value, it does appear the effect of this drug is real and that it can lower migraine frequency to some extent in some people. Now, as the drug is used over the next several years, we will learn more about just how effective it is.

Typically, when a new drug hits the market, there’s often a honeymoon phase, so there’s lots of good press. We get a good placebo response, everybody’s excited about it. Then, over time after about a year or so, that phase wears off and we get a little bit more accurate picture of what the drug really does. We also hope that at some point we will get some independent trials of the drug that are not funded by the company that’s making it.

So usually, it takes a few years after a drug hits the market, for us to really understand its impact in the clinic. The second pro of Aimovig is the tolerability seems to very good so far. One of the issues with the preventative medications are the side effects, as some of you probably know, Topamax, which I mentioned earlier can have some unpleasant side effects, most commonly some cognitive effects where people have difficulty finding words, they may have numbness and tingling, it can predispose to kidney stones and things like that.

In most of the migraine preventatives that are available, do have side effects that are experienced by a reasonable number of people who take them and so that limits their use to some degree. While we don’t have any head to head trials that compare the Aimovig to the existing treatments, which is what you really like to make these kind of comparisons, it does seem that it’s better tolerated at least so far than most of the other preventatives that are available.

All in all, the effectiveness seems to be at least as good as the other available preventatives and it may be the fact that its side effect profile is better. We don’t have a lot of information to go on. We’re really talking about side effects in the short term. The trial that I mentioned before of Aimovig lasted for six months.

The third pro is that the drug is long lasting. This could see as both a pro and a potential con, which I’ll discuss in a minute. But the good part about it being long lasting is that it doesn’t have to be taken every day, which typically helps with compliance. You don’t have to remember to take a medicine every day and for preventative medications, if you don’t take them, they’re not gonna do their job. You can’t wait til you have a migraine to take one.

The reason it lasts a while is because it’s an antibody, as I mentioned. So it’s not a drug. It’s not metabolized like a drug typically would be, but rather, it’s a function of how long the antibody lasts in our system. Aimovig is given once a month by injection and another benefit of this being a longer lasting medication is that since it is only delivered only by either injection or IV as with the other drugs in this class, that means fewer pokes with the needle.

Our fourth pro, which I think is the most significant pro of all is that this is the first migraine specific preventative medication that has ever come out. The other drugs that are used for migraine prevention and that are approved were not originally developed for that. They were either developed as anti seizure medications, anti hypertension medications, or antidepressants and then were tested for use for migraine prevention and then found to be of some benefit.

That’s the history of a lot of drugs is that somebody finds or creates a new molecule and then they just throw it at a bunch of things to see what it might help for. In this case, as I mentioned earlier, this began with the identification of CGRP as molecule that was involved in migraine pathophysiology which then led to the search for a drug that could modify its action in a way that would reduce the frequency of migraines.

The fact that we’ve gone from that scientific observation years ago to now having a drug available that actually does that, now, this is more of a scientific achievement. In other words, this is an important milestone in science and in particular in migraine research, even if it’s not a breakthrough in terms of migraine therapy.

But this is the first in a new and entirely new class of molecules that were designed specifically for treatment of migraine and it’s possible that our approach will get more sophisticated and that years down the line we’ll have something that’s even more effective or closer to a real therapeutic breakthrough.

All right, so those are four of the most significant pros in my mind. Now we’ll discuss what I kind of consider as the cons or the drawbacks at this point in time. The first con for Aimovig and any other drugs in its class, at least initially is that our information on them is still very limited. So probably the biggest negative right now is that this is brand new.

We don’t have all the information we’d like to have to make an informed decision, so things like side effects, both in the short and long term, as well as any other long term risks and overall long term effectiveness. As I mentioned earlier, we still don’t know very much about CGRP, what it does, except the fact that it’s wide spread, meaning it’s found throughout the body and throughout the nervous system, which means that it’s like to be important in a wide range of physiological processes.

So, that means we have really no idea how to predict all of the possible consequences of blocking the receptor of this molecule. Clearly our body is making it for a reason, meaning it probably does some very important things and what we’re doing with this drug is blocking its ability to do so, at least to some degree.

What we’re essentially doing is creating an autoimmune condition on purpose. Autoimmune illnesses like multiple sclerosis and lupus and rheumatoid arthritis occur when our body’s immune system attacks and destroys part of itself. As I mentioned earlier, this is exactly how this drug works and the other drugs in this class are going to work.

We’re essentially creating an autoimmune condition, in this case where we’re attacking our own receptors for CGRP or the CGRP molecule itself. Now, we’re assuming at this point in time that because people who are on it on this short term trial didn’t have any major adverse reactions that there aren’t any real significant downsides to doing this. To me, that would be fairly surprising if that turned out to be true.

It’s not at all unlikely that we may find certain issues or negative consequences that arise with longer term therapy. One of the problems is, when we don’t have a lot of information on something, we don’t really understand how it works completely, we really don’t know what to look for in a clinical trial. I know from experience being an investigator in clinical trials that it’s really challenging to detect problems if you don’t know what you’re looking for.

It’s possible even that there are short term issues associated with the drug that weren’t picked up in the trial simply because we didn’t know what to look for. Of course, we’ve seen over history, this sort of thing happen time and again where a drug comes out and only over time do we learn of risks and negative consequences that we didn’t initially know about but that emerged several years later, either because they just weren’t detected, or in some cases because they were detected but hidden.

One of the more high profile cases of this was the drug Vioxx, which was approved in 1999 and quickly became one of the best selling drugs, it’s an antiinflammatory drug that doesn’t bother the stomach like some of the others, yet it increased the risk of heart attacks and strokes, a company Merck that manufactured it hadn’t disclosed some of the heart attacks that had occurred.

Ultimately, it was pulled from the market, though there was still risks that remained after taking the drug, so it didn’t immediately stop after someone stopped taking it. And, one study concluded that there were 88 thousand heart attacks, 38 thousand of which were fatal simply from the prescription, from the prescribing of Vioxx.

Again, part of this is because it hadn’t been disclosed by the company that some of the heart attacks that had occurred … Again, this is a really challenging problem whenever you have billions of dollars on the line. It’s pretty crazy to think that you can get unbiased information, it’s just sort of a byproduct of the system that we have.

Another issue of not having all the information that we want because this is a new drug, is also that the information that we do have is mainly coming from those that have a vested interest in over emphasizing the positive aspects of the drug and downplaying any negative aspects and we’ve talked in our Facebook group before about the challenge of getting unbiased information about pharmaceuticals. It’s really difficult and a significant problem in this day in age, even for doctors to get unbiased information.

That’s largely because of the increasingly close relationship between the drug industry and healthcare providers, which wasn’t always the case but has become much more significant in the past couple of decades.

So, with so much money at stake, there’s a lot of money changing hands in an effort to try to influence doctor’s prescribing behaviors and you’ll often find that many of the most vocal advocates of a particular drug are receiving money from the company that makes it. Within the past decade, there was legislation passed that forced drug companies to disclose what payments had been paid to doctors and now there’s even a website you can go and look up any doctor and find how much money he or she receives every year from the various drug companies.

Some people might be surprised by what they find. Needless to say, there are big time conflicts of interest which compromise our ability to get unbiased information. With a brand new drug, this is even more challenging because literally all the information we’re getting on its safety and effectiveness is coming from the trials that are sponsored by the company.

All in all, there’s really just not the kind of information that we’d like to have to make an informed decision at this point of time right after a drug has come out. It’s just not possible at this stage in the game. That’s why I generally, regardless of what drug it is, I generally don’t recommend being an early adopter of a medication unless a drug has incredible benefits or is potentially life saving.

I think it’s best to think of the first several years of a drug as still an experimental phase. It takes at least a good five or 10 years for it to be used in the real world, in the clinic, before we have decent enough amount of information to make at least somewhat of an informed decision.

Now, the second con is that it’s expensive. What I saw is the estimated cost is about seven thousand dollars per year for the monthly injections. Now, compared to all of the available drugs our there, especially new drugs, that’s not as steep as it might be, and most folks who are receiving it won’t be paying that entire amount out of pocket.

More than likely you’ll be paying some sort of copay and that copay will probably be on the higher side. Most new drugs are going to be lower tier in an insurance company’s formulary meaning they’ll play less of the cost than ones that are on a higher tier. There’s likely to be a decent expense for you the patient, though you won’t probably foot the entire seven thousand dollar a year bill and there may be some assistance programs that folks may qualify for.

The third con is that the benefits of the drug, at least from the trial that has been done are somewhat modest. Like I said, they’re about on par with the results that came from the trials of Topamax and in a scenario like this where there’s still a lot of uncertainty where we don’t really know the long term risks and where there’s some reason to believe that there could be such a thing, we’d want the treatment to work really, really well before we accepted that risk, at least I would personally.

If every person in the trial never had a migraine again, then that would be certainly more motivation to take one the risks that come with adopting a drug like this right off the bat. The fourth con is that this type of treatment kind of represents the best available thing within all the constraints that our current system for finding medical therapies imposes.

This is an issue that almost never gets discussed or talked about, but is relevant to anyone who’s trying to make an informed decision in the confines of the traditional healthcare system, particularly in the US and most western influenced system. And that is, that the treatments that are delivered that are available inside of these systems have to fit within all of the constraints that are imposed as part of that system.

What I mean by that is there’s a huge set of hoops that are both formal and informal that any treatment has to clear or jump through before it can be offered in a conventional medical clinic. Number one, it almost always will have to be something that can be patented so that it can be produced on a large enough scale and that somebody can make money from it.

It also has to be testable within the confines of a randomized clinical trial like I discussed above. That almost means some single treatment that can be randomized where one groups gets the treatment and one group doesn’t. It also has to be something that can be delivered or administered in a very short timeframe, so within the span of a typical office visit.

Right there with those criteria, we’ve essentially excluded anything in the realm of diet and lifestyle treatments or really any type of holistic systems based treatment. None of those treatments would be able to fit within those constraints. Another one is that the treatment has to be something that’s going to be accepted by the typical patient.

Right now, the typical patient, not surprisingly, comes into a clinic expecting to receive a drug treatment and aren’t usually willing to make significant lifestyle and behavioral changes. All in all, this means that the reason that we have drug therapies as our main treatments, isn’t because they’re the best available treatment, it’s because they fit within the constraints of that system so that the available drugs are simply the best ones that fit within those constraints.

As an analogy, imagine that you were trying to build the very best house that you could, but you only had styrofoam, glue, and rubber bands as your materials. You might go through many different house designs and ways of putting those things together, and you’d certainly find certain designs and certain ways of building the house from those materials that were better than another one, but, of course, compared to a house that used all of the available materials we have for building, you’re house made of styrofoam, glue, and rubber bands wouldn’t be nearly as sturdy or as suitable for inhabiting.

The available treatments that we have inside of the medical clinic aren’t there because they’re the best of all possible solutions, it’s just that they’re the ones that are the best within the constraints that we’ve imposed from that system. But the problem is, most of us don’t appreciate that in this system, we’re not trying to find the very best house design, but rather we’re trying to build the best house made of styrofoam, glue, and rubber bands.

This is one of the primary reasons why there’s been almost no progress in the world of medical treatments over the past couple of decades. Even as we’ve had incredible technological advancements and transformations of our daily life, and other areas, including in medical diagnostic tools, but what we’ve done is created a system that makes it virtually impossible to find solutions that work for the conditions that we now face.

This is a big reason why, once I realized that I couldn’t offer my patients the very thing that would solve the problem I was supposed to help them solve, I had to find another way to do so. I wanted access to all of the available tools and materials, not just a tiny little subset.

Even worse was the fact that many of those treatments ultimately made their problem worse and especially in the case of migraines as I’ve discussed. So, this is the main reason why I advocate primarily for a drug free strategy. Not because there’s anything inherently wrong with drugs, but it’s because I want the thing that works the best because I realize how limited that approach is.

The problem with not recognizing that these drugs are the best thing we have within the constraints that we’ve imposed is that we end up seeing drugs as the only tool. And if we were to break down all of the things that we could do to protect ourselves from migraines and rank them in order of their effectiveness, drugs, any drug, would be way down on the list.

If you consider that they also come with potential harms and side effects, which drug free approaches don’t have, on the contrary, they often have health promoting effects, then you’d bump that down even further on your priority list. That being said, there are still situations where it may make sense to use them, at least in the short term, and I’ll discuss that in just a second.

The fifth con, which is somewhat individual is that there is needles involved. For some people, needles are a no go, they won’t consider any treatment that involves poking. But as I said, most of these are fairly infrequently delivered treatments, maybe about once a month, so you get poked about once a month. But most people tend to prefer swallowing a pill to being poked by a needle.

And the sixth and final con is that this treatment doesn’t address the root cause of migraines. As I mentioned Aimovig and the other drugs in this category target CGRP or the CGRP receptors, which is a part of migraine physiology. It’s part of the pain signaling, it happens after the migraine process has been initiated.

It’s definitely not treating migraines at their source or at their root cause and there are a few reasons why I’d consider this to be a con or a drawback. One is that, root cause treatments are almost always going to be the most effective and oftentimes treatments that don’t address root causes and just treat symptoms keep us from looking into or finding the root causes and in some instances may end up making the underlying condition worse.

This has become an even bigger problem in the last half century or so as more and more of the conditions that we see in the healthcare clinic are systemic and multifactorial like migraines, so they’re not well suited for a drug approach that can only target a single thing, but are sort of single minded focused on drugs as the only real tool, means that all we can ever really do in these instances is reduce symptoms.

That’s essentially stopped us collectively from looking toward root cause approaches. Nowadays, the typical approach to finding treatments is to kind of throw the available molecules and drugs that we have at a condition and see what works both in the research lab and in the medical clinic.

So take the example of type two diabetes. We know that it’s primarily an issue of diet and lifestyle, or at least it requires that environmental component. Yet, the treatments for diabetes basically allow you to engage in the very behaviors that brought the condition on in the first place.

Many people can get their sugar under reasonably good control with a pill or drug, which allows people to continue to eat the foods and lead lifestyles that led to that problem developing to begin with rather than addressing those root causes of diet and lifestyle that were a big part of it to begin with and were part of the root cause.

Another reason why this not being a root cause treatment is a downside is, I’ve talked before about there being a silver lining with migraines, which is they can be seen as kind of a canary in the coal mine alerting us when there are disturbances in the body that are harmful that are stressing or overburdening our brain and our body’s homeostatic capacities and if we listen to that signal, and we adjust our behavior accordingly, then not only will we have fewer migraines, but we will also enjoy much better long term health and wellbeing.

For example, with Amy’s comments that I read earlier, it was not being able to get the drug immediately that led her to took for other possible solutions and stumble on the Migraine Miracle Plan and now she’s fully on board with that and is not interested in drugs anymore.

Oftentimes that’s the issue, is that the drugs keep us from looking into those most transformative root cause treatments. Really, that’s the central message here, which is not that drugs are bad, but there are so many other effective treatments that are being completely ignored because we just have single mindedly focused on that as the only tool, so they only get a disproportionate amount of attention. It’s as if we’ve forgotten that you can build houses out of something other than styrofoam, rubber bands, and glue, which leads people to miss out on therapies and treatments that could be much more powerful and effective.

So with all of those pros and cons in mind, where do I as a neurologist see the role of Aimovig and the other drugs in this class that may follow? One scenario I can see it being used, is for those who are unwilling or unable to make holistic diet and lifestyle changes that address root causes. I think it’s a reasonable option in that scenario.

At the end of the day, my main concern is reducing suffering and in a perfect world everybody would adopt the best course of treatment. But I’m a realist being in the health care clinic for over a decade has taught me that. I know that not everyone is ready to do those sorts of things. This is a reasonable option in those situations.

Now, as I said, I’m apprehensive about being an early adopter for things like this and I think that history tells us that there is plenty of reason to be apprehensive. So, I won’t strongly advocate for it until it’s been proven in the real world. So, right now, I’m most apt to prescribe it for those who ask for it and who are comfortable with the risks.

Then for those who are willing to adopt a holistic approach like the Migraine Miracle Plan, but who are in dyer straights, particularly in the very depths of rebound headaches and really need any extra boost they can get, I think it’s a reasonable consideration in that scenario as well. In this instance, I’d favor using it as a short term treatment as a kind of temporary aid until rebound had been broken and the other changes had had enough time to take effect.

As you probably know, my primary objective is to get people to migraine freedom without pills mainly because the pills, the drugs, make it harder to get to migraine freedom. But there are certainly scenarios where the drugs can actually act as an aid to getting you to that point. Ultimately, all that matters to me is trying to find the fastest and most effective approach to ending suffering from the beast, and I’m fine with using every available tool I have to do that.

Just as a final summation, on the plus side, Aimovig and the other drugs in this class I think are a significant scientific milestone, even if they’re not a therapeutic breakthrough. And while this isn’t a panacea, it can certainly improve the quality of life for some people, especially if it’s used thoughtfully.

On the other hand, if we were to divide all of the things that we can do to strengthen our protection against the beast, a topic I covered in the last episode, this would be pretty far down on the list.

Okay, so that concludes this discussion on Aimovig and the new class of CGRP drugs. Hopefully you found this helpful. Clearly these things aren’t black and white. I think this discussion illustrates why medicine is referred to as an art, because it’s messy and there are a lot of different considerations and seldom are things as cut and dry as we’d like them to be, so we are almost always operating without all the information we’d like and trying to deal primarily with probabilities in a very imperfect system.

If you have any questions or comments about this episode, please feel free to leave them inside of our Facebook group and if you are wanting to adopt a root cause approach to migraines to slay the beast once and for all, head over to mymigrainemiracle.com and click on our resources link to see all the things that we have available to help you get there.

Okay, thanks so much for listening. Now it’s time to go out and slay the beast.

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