Researchers from Italy reported the case of a patient with chronic migraine and generalized myasthenia gravis (MG) who was treated with fremanezumab and plasmapheresis (PEX) at the same time. 

“Fremanezumab was dosed right after a PEX session,” the researchers wrote, “and the efficacy of both treatments was maintained.”

Read more about the treatment of MG

This case suggests that PEX does not reduce the efficacy of anticalcitonin gene-related peptide antibodies such as fremanezumab when the right intervals between the 2 treatments are scheduled.

The patient was a 57-year-old female who had generalized MG and chronic migraine. She was hypersensitive to aminopenicillins and had gluten and lactose intolerance. She suffered from deep vein thrombosis, and genetic testing revealed she had a homozygous mutation in the methylenetetrahydrofolate reductase MTHFR gene.

She had been experiencing migraines since her youth, for which she took many medications over the years. The researchers reported that she fulfilled the criteria for medication-overuse headache, according to the International Classification of Headache Disorders. 

Many preventive treatments were tried but were either ineffective, caused side effects, or were contraindicated due to her MG.

She was treated with corticosteroids to reduce the symptoms of MG, but this had little benefit and increased side effects. Azathioprine treatment was tried but discontinued due to side effects. Intravenous or subcutaneous immunoglobulins were not an option because of her previous deep vein thrombosis and MTHFR mutation. PEX was, therefore, the treatment of choice.

She continued to experience migraine and also suffered from depression and anxiety. Fremanezumab was considered and was given 4 to 7 days after a PEX session or in the middle of 2 PEX sessions to maintain the drug’s biological activity and to optimize the clinical response. 

She reported significant clinical benefits after the first month of treatment and no side effects during the 6-month follow-up. 

“This case broadens the drug’s clinical applications, and it helps in choosing the appropriate medical regimen in patients requiring both treatments,” the researchers concluded. 


Carmillo L, Fasano A. Fremanezumab plus plasmapheresis in a patient with chronic migraine and myasthenia gravis: case report of an effective treatment. Headache. Published online April 10, 2023. doi:10.1111/head.14497