• Lanfranco Pellesi, David Garcia-Azorin, Eloisa Rubio-Beltrán, Wook-Seok Ha, Roberta Messina, Raffaele Ornello, Igor Petrusic, Bianca Raffaelli, Alejandro Labastida-Ramirez, Ruth Ruscheweyh, Claudio Tana, Doga Vuralli, Marta Waliszewska-Prosół, Wei Wang, and William Wells-Gatnik.
• Department of Public Health, Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Campusvej 55, Odense, 5230, Denmark. lpellesi@health.sdu.dk.
• J Headache Pain. 2024 Dec 5; 25 (1): 214214.

AbstractCombination treatments for migraine prophylaxis present a promising approach to addressing the diverse and complex mechanisms underlying migraine. This review explores the potential of combining oral conventional prophylactics, onabotulinumtoxin A, monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway, and small molecule CGRP receptor antagonists (gepants). Among the most promising strategies, dual CGRP inhibition through mAbs and gepants may enhance efficacy by targeting both the CGRP peptide and its receptor, while the combination of onabotulinumtoxin A with CGRP treatments offers synergistic pain relief. Oral non-CGRP treatments, which are accessible and often prescribed for patients with comorbid conditions, provide an affordable and practical option in combination regimens. Despite the potential of these combinations, there is a lack of evidence to support their widespread inclusion in clinical guidelines. The high cost of certain combinations, such as onabotulinumtoxin A with a CGRP mAb or dual anti-CGRP mAbs, presents feasibility challenges. Further large-scale trials are needed to establish safe and effective combination protocols and solidify their role in clinical practice, particularly for treatment-resistant patients.© 2024. The Author(s).

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