1.1 Erenumab is recommended as an option for preventing migraine in adults, only if:
they have 4 or more migraine days a month
at least 3 preventive drug treatments have failed
the 140 mg dose of erenumab is used and
the company provides it according to the commercial arrangement.
1.2 Stop erenumab after 12 weeks of treatment if:
in episodic migraine (less than 15 headache days a month) the frequency does not reduce by at least 50%
in chronic migraine (15 headache days a month or more with at least 8 of those having features of migraine) the frequency does not reduce by at least 30%.
1.3 These recommendations are not intended to affect treatment with erenumab that was started in the NHS before this guidance was published. People having treatment outside these recommendations may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.
Why the committee made these recommendations
Treatments for preventing chronic or episodic migraine include beta-blockers, antidepressants and antiepileptic drugs. If chronic migraine does not respond to at least 3 preventive drug treatments, botulinum toxin type A or best supportive care (treatment for the migraine symptoms) is offered. If episodic migraine does not respond to at least 3 preventive drug treatments, best supportive care is offered.
For people whose migraine has not responded to at least 3 preventive treatments, the clinical trial evidence shows that erenumab 140 mg works better than best supportive care for preventing chronic or episodic migraine. There is no direct evidence comparing erenumab with botulinum toxin type A in chronic migraine, but an indirect comparison suggests that erenumab has some benefit. It is plausible that erenumab may work better than botulinum toxin type A.
The cost-effectiveness estimates are within what NICE usually considers an acceptable use of NHS resources. So erenumab is recommended for preventing migraine in adults who have at least 4 migraine days per month.