Reasons for discontinuation of CGRP antibody therapy: Insights from a retrospective real-world cohort study

Aim Calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) have expanded preventive treatment options for migraine, especially in patients with previous prophylactic failures. While their efficacy and tolerability are well established, reasons for treatment discontinuation remain insufficiently characterized. This study aimed to systematically evaluate discontinuation rates and underlying reasons for stopping CGRP mAb therapy in a real-world cohort of drug-resistant migraine patients. Methods This retrospective, single-center cohort study included adults with episodic or chronic migraine treated with erenumab, galcanezumab, or fremanezumab at the West German Headache Center. Baseline clinical characteristics, monthly headache and migraine days, and acute medication intake were extracted from routine clinical documentation. Treatment status was assessed via medical records and telephone verification. Reasons for discontinuation were self-reported and categorized as perceived lack of effectiveness, adverse events, or subjective remission. Results Of 252 included patients, 74.6% ( n = 188) continued therapy, while 25.4% ( n = 64) discontinued. Perceived ineffectiveness was the most common reason for discontinuation (67.2%, n = 43), and 76.7% ( n = 33) of these patients stopped within six months. Only 9.3% ( n = 4) reported secondary loss of effectiveness after an initial response. Patient-reported qualitative improvements—such as reduced attack intensity or duration—were frequent among patients who continued treatment, even when formal response criteria based on monthly headache days (MHDs) were not met. Prior responsiveness to triptans was associated with continuation of therapy. Conclusion In this real-world cohort of drug-resistant migraine, treatment persistence with CGRP mAbs was high. Most discontinuations occurred within six months and were driven by perceived lack of effectiveness. Qualitative improvements beyond reductions in MHDs were important factors contributing to continued therapy. These findings highlight the relevance of patient-reported improvements in clinical decision-making.