Migraine Prophylaxis Using Novel Monoclonal Antibody Injections in a Commercial Pilot

BACKGROUND: Frequent migraine headaches are disabling and aeromedically disqualifying. Four new monoclonal antibody medications, targeting calcitonin gene-related peptide (CGRP), have been approved by the U.S. Food and Drug Administration (FDA) since 2018, with more expected in the coming years. These medications present new alternatives for the treatment of migraine unresponsive to other therapeutic and prophylactic agents.CASE REPORT: We present a case of a 45-yr-old commercial pilot who presented with migraine headaches increasing in frequency to 1315 per month in spite of the use of propranolol for prophylaxis and sumatriptan for abortive treatment of the headaches. Upon presentation, he was not flying due to his frequent headaches and he was started on monthly subcutaneous injections of fremanezumab. Following his second injection, his headaches stopped entirely, and he has continued on the medication and not experienced another migraine headache. He underwent an aeromedical neurology evaluation and consideration for Authorization of Special Issuance of Medical Certificate, which was granted by the Federal Aviation Administration (FAA).DISCUSSION: This is the first case to our knowledge of the successful use of an anti-CGRP monoclonal antibody medication in an active pilot. The pilot appears to be a super responder to the medication, having achieved complete remission of a nearly life-long condition. Though only a small portion of treated individuals will see this sort of response, these medications represent an effective additional option for migraine prophylaxis in the pilot population.Garber MA, Sirven JI, Roth RS, Hemphill JM.