CGRP-Targeted Migraine Therapies in Patients With Vascular Risk Factors or Stroke

Dr. Tesha Monteith and Dr. Michael Eller discuss the implications of CGRP therapies in migraine treatment, particularly for patients with vascular risk factors or a history of stroke.

Show citation:

Eller MT, Schwarzová K, Gufler L, et al. CGRP-Targeted Migraine Therapies in Patients With Vascular Risk Factors or Stroke: A Review. Neurology. 2025;105(2):e213852. doi:10.1212/WNL.0000000000213852

Show transcript:

Dr. Tesha Monteith:

Hi, this is Tesha Monteith with the Neurology Minute. I've just been speaking with Michael Eller from the Department of Neurology Medical University of Innsbruck, Austria on the neurology podcast on his paper, CGRP Targeted Migraine Therapies in Patients with Vascular Risk Factors or Stroke: A Review.

Hi, Michael.

Dr. Michael Eller:

Hello.

Dr. Tesha Monteith:

Why don't you summarize your general approach to use of CGRP targeted therapies in patients that might be at risk for vascular events when considering safety?

Dr. Michael Eller:

Yeah. About acute vascular events, we should stop CGLP targeted drugs immediately. When we come to post-stroke, we should reassess the necessity of these targeted treatments after recovery. We suggest a minimum of three months pause after ischemic stroke to allow early recovery and remodeling, and then restart only after individualized benefit risk review.

In high-risk primary prevention, so no stroke yet, but elevated risk, if the patients are 65 years or older with established cardiovascular disease, we should prefer traditional preventives. And if CGLP targeted therapy is essential, we should consider Gepants cautiously due to their shorter half lives.

We should avoid CGLP targeted treatments in small vessel disease, distal stenosis, Raynaud's phenomenon, and uncontrolled hypertension. For acute migraine treatment, we can consider gepants or ditans as alternatives to triptans and NSAIDs in relevant stroke risk or post-stroke patients, individualized to comorbidities.

Dr. Tesha Monteith:

Great.

And we should say that the label updates include hypertension and Raynaud's phenomenon as potential vascular complications. Otherwise, these are more theoretical risks based on what we know about CGRP.

Dr. Michael Eller:

Yes, I totally agree because large studies did not show any elevated cardiovascular risk signals. And for post-marketing databases, we did not see any elevated cardiovascular risk so far. However, in pre-clinical settings, studies showed large infarct size in pretreated mice.

Dr. Tesha Monteith:

Great. Well, thank you again for doing this work. It was a phenomenal read and congratulations.

Dr. Michael Eller:

Thank you.

Dr. Tesha Monteith:

This is Tesha Monteith. Thank you for listening to the Neurology Minute.