203 Safety considerations in the treatment with anti-CGRP antibodies 9 DISCUSSION This study investigated the long-term safety of anti-CGRP(R)-mAbs as migraine treatment. Among all patients, 3.11% developed abnormal ECG or CV adverse events during treatment with erenumab (n=3) or fremanezumab (n=3). Within this group, 1.55% developed moderate to severe CV adverse events that led to treatment discontinuation. These adverse events included cerebellar stroke, SCAD, and pericarditis. The remaining 1.55% developed non-threatening ECG abnormalities without physical complaints. It is noteworthy that these events occurred in patients with no prior hypertension and no prior CV complaints. No clinically meaningful changes were observed in liver, kidney function, lipid, electrolyte, or glucose levels over time. Migraine itself is associated with an elevated risk of myocardial infarction (OR 2.2, 95% CI 1.7–2.8) and stroke (OR 1.5, 95% CI 1.2–2.1).26 It is important to note that the absolute risk of CV disease in patients with migraine remains generally low, and is influenced by various factors, including migraine subtype, age, sex and the presence of additional risk factors. In a large population-based study spanning 11.9 years, 697 CV events consisting of both stroke or myocardial infarction were reported among 3577 women with migraine, resulting in an annual incidence of 1.64%.27 Another population-based study among people with migraine reported cumulative incidences over 19 years for myocardial infarction and ischemic stroke separately. Specifically, for myocardial infarction, there were 25 cases per 1000 people, which translates to an annual incidence of 0.13%. For ischemic stroke, the study found 45 cases per 1000 people, resulting in an annual incidence of 0.24%.28 We recognize the inherent complexity in directly comparing our cohort study with population-based studies. Our selection process may introduce bias by favoring patients with fewer CV risk factors or more severe migraine cases. Additionally, our study encompasses non-ischemic CV events, including pericarditis. Nonetheless, our findings align with these population-based studies. We identified one individual with an ischemic stroke within a 1.5-year follow-up period, resulting in an annual incidence rate of 0.34% for ischemic stroke. To our knowledge, there is no study investigating the association between pericarditis and migraine. Furthermore, although the lifetime prevalence of migraine seems to be elevated in individuals with SCAD compared to the general population,29 there are no studies investigating the incidence of SCAD specifically among patients with migraine. However, a history of migraine is correlated with an increased risk of cervical artery dissection, with an odds ratio of 1.74 (95% CI 1.38-2.19).30 The precise biological mechanisms underlying this association remain
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