Eller Michael Thomas, Schwarzová Katarína, Gufler Lena, Karisik Anel, Kaltseis Katharina, Frank Florian, Broessner Gregor
From the Department of Neurology, Medical University of Innsbruck, Austria.
Neurology. 2025 Jul 22;105(2):e213852. doi: 10.1212/WNL.0000000000213852. Epub 2025 Jun 19.
Calcitonin gene-related peptide (CGRP)-targeted therapies, including monoclonal antibodies (mAbs) and gepants, represent a major advancement in migraine prevention, offering greater efficacy and improved tolerability compared with traditional treatments. These agents selectively inhibit the CGRP pathway, a key mediator in migraine pathophysiology, and are increasingly used even as first-line options in selected patients. While clinical trials and real-world data suggest a favorable cardiovascular (CV) safety profile, particularly in patients without major risk factors, evidence remains limited for those with established vascular disease or recent vascular events. Concerns persist regarding long-term effects and the safety of CGRP blockade in high-risk populations. This narrative review focuses on the CV and cerebrovascular safety of CGRP-targeted migraine treatments-an area of growing clinical relevance. We compare these newer agents with traditional migraine preventives and highlight the paucity of data in patients with previous stroke, subarachnoid hemorrhage, myocardial infarction, or significant CV comorbidities. In addition, we discuss the emerging topic of dual CGRP pathway blockade (mAbs plus gepants), which has not previously been reviewed in the context of vascular risk. Based on currently available scientific evidence, we offer structured clinical considerations to guide the use of CGRP-targeted therapies in patients with vascular risk or cerebrovascular disease. Our aim is to support informed decision making in a population that has often been excluded from clinical trials but is becoming increasingly important in clinical practice.
降钙素基因相关肽（CGRP）靶向疗法，包括单克隆抗体（mAb）和 gepants，是偏头痛预防领域的一项重大进展，与传统治疗相比，疗效更佳且耐受性更好。这些药物选择性抑制 CGRP 通路，这是偏头痛病理生理学中的关键介质，甚至在特定患者中越来越多地被用作一线选择。虽然临床试验和真实世界数据表明其心血管（CV）安全性良好，尤其是在没有主要危险因素的患者中，但对于患有已确诊血管疾病或近期发生血管事件的患者，证据仍然有限。对于高危人群中 CGRP 阻断的长期影响和安全性的担忧依然存在。本叙述性综述聚焦于 CGRP 靶向偏头痛治疗的心血管和脑血管安全性——这一临床相关性日益增加的领域。我们将这些新型药物与传统偏头痛预防性药物进行比较，并强调既往有中风、蛛网膜下腔出血、心肌梗死或严重心血管合并症的患者数据匮乏。此外，我们讨论了双 CGRP 通路阻断（单克隆抗体加 gepants）这一新兴话题，此前尚未在血管风险背景下进行过综述。基于目前可用的科学证据，我们提供结构化的临床考量，以指导在有血管风险或脑血管疾病的患者中使用 CGRP 靶向疗法。我们的目的是支持在一个通常被排除在临床试验之外但在临床实践中变得越来越重要的人群中做出明智的决策。
