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Fremanezumab for the prevention of chronic migraine (prefilled syringe)

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Fremanezumab for the prevention of chronic migraine (prefilled syringe)

Who is this information for? What is its aim?

You have been prescribed Fremanezumab (known as AJOVY) to help treat chronic migraine.

About fremanezumab

Fremanezumab is from a new group of medicines designed to bind to a substance called Calcitonin Gene-Related Peptide (CGRP) and block its ability to act and interact with its receptor. These medicines are known as monoclonal antibodies (mAbs). They are designed as antibodies that recognise and bind to the CGRP but have no other known interference with the immune system. This group of medicines has arisen from recent advances in our understanding of migraine and is the first preventative medicine designed specifically for migraine. It has been demonstrated that during a migraine attack CGRP levels rise, which can be temporarily blocked by migraine specific pain relief medications (medications specifically from the triptan group), however the CGRP mAbs are able to do this effectively on a long term basis.

The clinical trials have shown that it can be a very effective treatment in some patients with migraine, with 30-50% of patients reporting reduction in their migraine days by at least a half or more.

This medicine will be considered by your hospital doctor if you have:

  • chronic migraine (more than 15 headache days per month, of which 8 days have migrainous features, and this has been the case for at least 3 months);
  • addressed any pain relief overuse;
  • tried at least three preventative drug treatments from different drug groups (and these have been deemed sufficient trials);
  • considered a trial of cranial botulinum treatment.

This medication comes as a pre-filled syringe containing 225mg of fremanezumab and is suitable for subcutaneous (just under the skin) self-delivery. When you first receive treatment you will be given monthly treatments but if you continue to receive treatment beyond three months you will be given a choice of receiving:

a) three injections consecutively at the start (i.e. 225mg x 3 = 675mg) with follow up at three months


b) having one injection (i.e. 225mg) every month for three months with follow up on completion of three months.

Both dosing schedules work as effectively but occasionally when the three injections are given at the start some patients may experience wearing off of therapeutic benefit towards the end of the three month duration.

If you miss or have to delay a dose then you should take the omitted dose at the earliest opportunity. The next scheduled dose should be re-adjusted from this time point, i.e. restart the three monthly or monthly clock. You must never administer a double dose to make up for a missed dose.

If you are going away on holiday then provided you can keep the medication chilled in a cool bag with a cold pack, so that the temperature will be less than 25oC, this is permissible providing you can ensure it is put back in the fridge at your destination within 24 hours. This must not be done repeatedly and should only be done on one occasion.

If you notice any worrying signs or symptoms please inform your general practitioner (GP) and neurologist as soon as possible.

Dosing schedule

Schedule A

Day and date started:

Schedule A - dosing schedule
No. of pre-filled syringes Total dose
Month 1 No. of pre-filled syringes 3 Total dose 675mg
Month 2 No. of pre-filled syringes 0 Total dose -
Month 3 No. of pre-filled syringes 0 Total dose -

Your neurologist will need to review you, together with your headache diary, in order to decide whether further treatment is advised. Further monthly 225mg or three monthly 675mg fremanezumab injections may be recommended.

Schedule B

Day and date started:

Schedule B - dosing schedule
No. of pre-filled syringes Total dose
Month 1 No. of pre-filled syringes 1 Total dose 225mg
Month 2 No. of pre-filled syringes 1 Total dose 225mg
Month 3 No. of pre-filled syringes 1 Total dose 225mg

Your neurologist will need to review you, together with your headache diary, in order to decide whether further treatment is advised. Further monthly 225mg or three monthly 675mg fremanezumab injections may be recommended.


  • Store in the refrigerator between 2-8°C.
  • Protect from light until time of administration and keep within the original outer container / box.
  • Do not freeze. Discard if this occurs.
  • Do not shake the pen. Discard if this occurs.

Method of administration

You will be provided with a supply of fremanezumab / AJOVY pre-filled syringes and will receive training by a healthcare specialist on administration before starting treatment.

Before injection
  1. Remove fremanezumab / AJOVY from the refrigerator. Depending on your dosing schedule this may be one or three pre-filled syringes. Immediately return any remaining pre-filled syringes back to the original container / box in the refrigerator. Allow the syringe/s you will be using to reach room temperature before administration. This will take approximately 30 minutes. If you have to transport the medication, e.g. from clinic to home, then we recommend use of a cool bag with cold pack to ensure the temperature is kept below 25oC at all times and that the medications is transferred to the fridge as soon as possible (note the product must be discarded if it has been out of the refrigerator for ≥ 24hrs). Once taken out of the refrigerator, and allowed to reach room temperature, the syringe/s must not be returned to the refrigerator.
  2. DO NOT attempt to re-heat.
    DO NOT leave the pre-filled syringe in direct sunlight.
    DO NOT shake the pre-filled syringe.
  3. Check that the pre-filled syringe is intact, untampered, has come from a box with the name fremanezumab / AJOVY on the label and is within the expiry date. The liquid should be clear and colourless to light yellow. Discard if the liquid is cloudy, discoloured, frozen or it contains visible particles. Air bubbles are normal and the pre-filled syringe is still safe for use.
  4. Collect the equipment you will need to administer treatment: alcohol wipe, cotton wool ball, dedicated bin that will be provided to collect all of the waste (called a yellow sharps bin) and the AJOVY pre-filled syringe.
  5. Wash your hands thoroughly and dry hands with a clean towel.
  6. Select the injection site – either the abdomen (at least two inches / five centimetres from belly button), the front of the thigh (at least two inches / five centimetres above the knee or two inches / five centimetres below the groin), the back of the upper arm or the buttocks. You should not inject into areas where the skin is tender, bruised, red, hardened, scarred, tattooed or has stretch marks. Choose a different injection site each time.
  7. Clean the chosen injection site with an alcohol wipe and leave to dry for a minimum of 10 seconds.
To inject
  1. Remove the cap from the needle. Once uncapped it must be used and you must not attempt to recap. DO NOT touch the needle or attempt to pull back on the plunger.
  2. Gently pinch at least 2.5cm / 1 inch of the skin you have cleaned.
  3. Insert the needle into the pinched skin at a 45-90 degree angle.
  4. Slowly push the plunger in as far as it will go to inject the drug fully.
  5. With care, fully remove the needle from your skin and discard the used syringe directly into the yellow sharps bin. This is a single use syringe, do not attempt to reuse.
  6. Apply gentle pressure at the injection site for a few seconds using a clean, dry cotton wool ball. DO NOT rub the injection site.
  7. If you are on the three monthly dosing schedule (Schedule A) then you will move on to consecutively administer two further injections following these same instructions until you have administered your total three syringes.
  8. Always discard and dispose of used syringe units in your yellow sharps bin and never attempt to throw away any part in your household waste. You must never attempt to recycle your sharps bin and when full it should be disposed of appropriately.

You may find the video (opens in a new tab) produced by the manufacturers of fremanezumab / AJOVY a useful reminder of how to administer the pre-filled syringes.

Side effects

As with all medications, there are potential side effects, which may occur in a small number of patients.

The most common reported effects, occurring in more than 10% of patients are:

  • mild to moderate injection site pain
  • skin reactions such as redness, bruising and swelling

Other less common reported effects include injection site itching and rash.

The majority of skin reactions are apparent within one hour and will resolve over 24 hours although injection site itch and rash often occurs 24-48 hours following injection.

Rarely reported side effects can include:

  • more significant allergy including itching, rash, hives (pale red bumps or wheals)
  • trouble breathing
  • swelling of the lips / tongue called angioedema

It is important to note that allergic reactions can occur days to a month after using fremanezumab. You should remain vigilant for signs or symptoms during this time.

Seek emergency medical review immediately if you have any of the following symptoms, which may be part of an allergic reaction:

  • swelling of your face, mouth, tongue, or throat 
  • difficulty breathing

Please ensure you inform any doctor / nurse / pharmacist involved in your care that you are being treated with fremanezumab / AJOVY.


Routine observations including your blood pressure and pulse rate should be performed prior to first starting treatment and these will be done in clinic by your neurology team. Routine blood tests including liver function (LFTs) will be performed by the hospital prior to commencing treatment, and if you continue treatment beyond three months, again at six months and this should be organised by the hospital or your GP. If the baseline test is abnormal this will need to be repeated at three monthly intervals in the first year.

In order to receive treatment it is essential that you keep a headache diary for the three months preceding treatment. You will be expected to complete your headache diary on a daily basis and present this to your neurologist at the time of review. Without an ongoing complete headache diary you will not be considered for treatment beyond three months.

Contraindications and cautions – note for medical specialists

Fremanezumab must not be used if the patient has had previous hypersensitivity to the active drug or to any of the product contents. Furthermore, fremanezumab must be used with caution if a patient has had previous significant hypersensitivity to another of the CGRP mAbs.

The clinical trials excluded those with significant cardiovascular or cerebrovascular disease. The relative safety in this group is unknown so it should be used with caution in any individual with recent acute cardiovascular events, including MI, unstable angina, CABG, stroke or DVT and / or those deemed to be at serious cardiovascular risk.

Interactions – note for medical specialists

No formal clinical drug interaction studies have been conducted. However there are no expected drug interactions based upon the characteristics of this compound.


Do not stop taking fremanezumab unless your doctor tells you to.

Pregnancy and breast feeding

Fremanezumab is not recommended for management of migraine if you are pregnant, actively planning a pregnancy or are breastfeeding. Women of childbearing age should take adequate contraceptive precautions. No data is available to recommend how long following stopping fremanezumab it is safe to become pregnant. We therefore recommend that on stopping fremanezumab contraception is maintained for a further six months, as it is considered this drug may stay within the body up to this time period.

This information should be read in conjunction with the product characteristic leaflet that can be found inside all boxes of medication. The use of any medicine is based on considerations of how benefits outweigh potential side effects. Your prescribing doctor will discuss the risks and benefits of the medication as it relates to you and answer any further questions you may have.

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Contact us

Cambridge University Hospitals
NHS Foundation Trust
Hills Road, Cambridge

Telephone +44 (0)1223 245151