Erenumab Dosage for Migraine Prevention

An Evidence-Based Narrative Review With Recommendations

Stewart J. Tepper MD; Huma U. Sheikh MD; Carrie O. Dougherty MD; Stephanie J. Nahas MD MSEd; Paul K. Winner DO; Ananda Krishna Karanam PhD; Andrew M. Blumenfeld MD; Ahmad Abdrabboh PharmD MPH; Soeren Rasmussen MD; Jamie L. Weiss PhD; Jessica Ailani MD


Headache. 2022;62(4):420-435. 

In This Article

Abstract and Introduction


Background: Therapeutic monoclonal antibodies against the calcitonin gene-related peptide (CGRP) receptor or its ligand have changed the landscape of treatment options for migraine. Erenumab is the first and only fully human monoclonal antibody designed to target and block the CGRP receptor. It is approved by the Food and Drug Administration for preventive treatment of migraine in adults. The recommended dose of erenumab is 70 mg monthly, with guidance that some patients may benefit from the 140 mg monthly dose. There is a need for information to guide clinical practice on the comparative efficacy and safety of these two dosing options.

Objective: To evaluate therapeutic and tolerability differences between erenumab 70 and 140 mg based on evidence from published literature.

Methods: This narrative review evaluates therapeutic and tolerability differences between erenumab 70 and 140 mg based on a literature search using PubMed interface, Embase and Ovid MEDLINE(R) databases. The key search terms included migraine, AMG 334, AMG334, erenumab, erenumab-aooe, and Aimovig. The search was limited to English language articles or conference abstracts published up to May 2021.

Results: From the literature search, we retrieved 23 relevant articles/conference abstracts (19 articles [5 randomized, double-blind studies] and 4 conference abstracts) for inclusion in this narrative review. Although the recommended starting dosage of erenumab is 70 mg, this narrative review of the literature indicates that some patients may benefit from a dosage of 140 mg erenumab once monthly—especially those with difficult-to-treat disease and prior treatment failures. The evidence indicates that erenumab at 140 mg has a numerically better efficacy than 70 mg across a broad spectrum of migraine outcomes, including preventing progression to chronic migraine.

Conclusion: Cumulative data from the literature support a therapeutic gain with an increase from erenumab 70 to 140 mg and a rationale for initiating 140 mg in selected patients.


Migraine is a common, disabling, and complex neurological disease and is the second leading cause of years lived with disability.[1] It has been established that calcitonin-gene related peptide (CGRP) plays a key role in the pathophysiology of migraine.[2] The monoclonal antibody (mAb) erenumab targets the CGRP receptor and reduces CGRP activity. Treatment with erenumab reduces the burden of migraine and improves patients' quality-of-life.[3] The American Headache Society (AHS) consensus statement[4] and European Headache Federation (EHF) guidelines[5] recommended the use of CGRP mAbs based on the robust clinical study data, especially in patients with significant disease burden (e.g., more than four disabling headache days a month).

Erenumab (erenumab-aooe in the United States; also known as AMG 334), a fully human mAb targeting canonical CGRP receptor,[6] is approved as a preventive treatment of migraine in adults in many parts of the world, including the United States and the European Union (Figure 1).[7–9] Results from the pivotal double-blind, placebo-controlled studies[10,11] have demonstrated that erenumab 70 and 140 mg are well tolerated and provide clinically meaningful benefits to individuals with episodic and chronic migraine (EM and CM). However, these studies were not designed to compare the two erenumab doses. Despite the availability of data on the individual dosing, gaps in our knowledge (Table 1) regarding the comparative efficacy and safety of the two erenumab doses still remain. To address these knowledge gaps, we examined the available evidence from the literature to explore differences in efficacy and/or tolerability between the erenumab doses of 70 and 140 mg.

Figure 1.

Erenumab mechanism of action. CGRP, calcitonin gene-related peptide; CLR, calcitonin receptor-like receptor; RAMP1, receptor activity-modifying protein [Color figure can be viewed at]