Comparative Effectiveness of Migraine Preventive Medications: The APT Comparison Study

1. Is the biology right?

• Somatic driver evidence: no · None of CALCRL, ADRB1, ADRB2, CA2, CA4, GRIA4 has somatic-mutation evidence in migraine disorder

  Rule: Open Targets has somatic-mutation evidence for the target in this cancer. Source: Open Targets: CALCRL in migraine disorder, 2026-11-12
• Human genetic evidence: no · No germline or somatic evidence for CALCRL, ADRB1, ADRB2, CA2, CA4, GRIA4 in migraine disorder

  Rule: Any germline or somatic human genetic evidence for the target in this cancer, counted apart from animal-model and literature evidence. Source: Open Targets: CALCRL in migraine disorder, 2026-11-12
• Pediatric target: no · Not on the FDA list

  Rule: Target is on FDA's Pediatric Molecular Target List (relevant targets); membership alone neither requires nor waives a study. Source: FDA Pediatric Molecular Target List (Listed as February 2026 on the FDA Pediatric Oncology page; the file served is 9.7.22_the_relevant_molecular_target_list.xlsx, whose Summary of Changes sheet is headed 'SEPTEMBER 2022 UPDATE' (footnote date 2022-09-01)), 2026-11-11
• Haematologic cancer: no · Solid tumour

  Rule: From the indication, or the registry conditions when no indication matches. Source: ClinicalTrials.gov NCT06972056, 2026-11-12

  Published context: Likelihood of approval from phase 1: 7.5% haematologic vs 4.6% solid (BIO / Informa / QLS 2021, 2011–2020). Population-level, not a prediction.

• CALCRL (via Atogepant): Evidence types in migraine disorder: literature, clinical; literature listed separately from human genetics. Datasources: clinical_precedence, europepmc. · Open Targets: CALCRL in migraine disorder
• ADRB1 (via Propranolol): Evidence types in migraine disorder: literature, clinical; literature listed separately from human genetics. Datasources: clinical_precedence, europepmc. · Open Targets: ADRB1 in migraine disorder
• ADRB2 (via Propranolol): Evidence types in migraine disorder: literature, clinical; literature listed separately from human genetics. Datasources: clinical_precedence, europepmc. · Open Targets: ADRB2 in migraine disorder
• CA2 (via Topiramate): Evidence types in migraine disorder: literature, clinical; literature listed separately from human genetics. Datasources: clinical_precedence, europepmc. · Open Targets: CA2 in migraine disorder
• CA4 (via Topiramate): Evidence types in migraine disorder: clinical. Datasources: clinical_precedence. · Open Targets: CA4 in migraine disorder
• GRIA4 (via Topiramate): Evidence types in migraine disorder: literature, clinical; literature listed separately from human genetics. Datasources: clinical_precedence, europepmc. · Open Targets: GRIA4 in migraine disorder

• Not loaded on this app yet: Normal-tissue expression in vital organs. Source: Human Protein Atlas (ticket 36).
• Not loaded on this app yet: Pan-essential in cell lines. Source: DepMap (ticket 36).
• Not loaded on this app yet: Approved drug on this target. Source: Drugs@FDA (ticket 30).

2. Can the result be trusted?

• Randomised: yes · Randomised allocation

  Rule: Registry allocation field. Source: ClinicalTrials.gov NCT06972056, 2026-11-12
• Small denominator: no · 1335 planned; each patient moves a rate by 100 ÷ 1335 = 0.1 points

  Rule: Enrolment under 30; the arithmetic is shown, not a benchmark. Source: ClinicalTrials.gov NCT06972056, 2026-11-12
• Primary endpoint is overall survival: no · Treatment Responder (atogepant vs. topiramate; atogepant vs. propranolol)

  Rule: A registered primary outcome measure names overall survival. Source: ClinicalTrials.gov NCT06972056, 2026-11-12

  Published context: Non-OS primary endpoint: odds ratio 2.79 for a positive phase 3 (Otsuka 2021, 400 phase 3 oncology trials, to 2020). Shown with the next figure: a surrogate is easier to hit, and often a weak guide to survival.

  Published context: 52% of surrogate-to-OS correlations are low (Prasad 2015, published to 2014). Shown with the figure above.
• Results overdue: no · Primary completion expected 2029-03-01; not yet due

  Rule: Primary completion (actual) more than 12 months ago and no results posted to the registry. Source: ClinicalTrials.gov NCT06972056, 2026-11-12

• Not loaded on this app yet: Treated and evaluable counts, assessor, confirmed response, follow-up and data cutoff. Source: Readout extraction (ticket 32).
• Not loaded on this app yet: Primary endpoint changed between registry versions. Source: Registry versions in the store (ticket 32).

3. What must it beat?

• Not loaded on this app yet: Control-arm result and approved therapies for the same segment, with label links. Source: Drugs@FDA, FDA labels and readouts (tickets 30, 32).

4. Too crowded, or too late?

• Stopped on this target: 20 terminated, withdrawn or suspended trials of drugs against CALCRL. Reasons are quoted as the registry gives them on the target page. · CALCRL: what already stopped

• Not loaded on this app yet: Programs on the target by phase and months behind the leader. Source: Programs and Drugs@FDA (ticket 33).

5. Can it be approved, and stay approved?

• Single-country: yes · All 37 sites in United States

  Rule: All listed sites are in one country; the share of US sites is shown. Source: ClinicalTrials.gov NCT06972056, 2026-11-12
• EU paediatric investigation plan: yes · EMA/PE/0000182928 (propranolol hydrochloride, Treatment of arrhythmias): P: decision agreeing on a investigation plan, with or without partial waiver(s) and or deferral(s), 15 Apr 2025; EMA/PE/0000225746 (atogepant, Prevention of migraine headaches): PM: decision on the application for modification of an agreed PIP, 2 Jan 2025; EMEA-000511-PIP01-08-M04 (propranolol hydrochloride, Treatment of haemangioma): PM: decision on the application for modification of an agreed PIP, 21 Jan 2013; compliance positive 14 Feb 2013; EMEA-000826-PIP01-09 (phentermine;topiramate, Treatment of obesity): W: decision granting a waiver in all age groups for all conditions or indications, 29 Oct 2010

  Rule: An EMA PIP decision (agreement, modification or waiver) lists the drug as its active substance, exact name. Source: EMA data download (dated snapshot), 2026-11-11
• EU orphan designation: yes · EU/3/24/2932 positive 28 Jun 2024: Treatment of neonatal encephalopathy; EU/3/22/2713 positive 11 Nov 2022: Treatment of familial cerebral cavernous malformations; EU/3/19/2217 positive 17 Oct 2019: Treatment of retinopathy of prematurity; EU/3/17/1841 positive 27 Feb 2017: Treatment of von Hippel-Lindau disease; +1 more

  Rule: An EU orphan designation lists the drug as its active substance (exact name) or belongs to a medicine that does; withdrawn and expired designations are listed with their status. Source: EMA data download (dated snapshot), 2026-11-11
• Authorised in the EU: yes · Aquipta: authorised since 11 Aug 2023; Hemangiol: authorised since 23 Apr 2014; Qsiva: refused

  Rule: An EMA medicine record lists the drug as its active substance or INN, exact name; national-only authorisations are not in this file. Source: EMA data download (dated snapshot), 2026-11-11
• FDA orphan designation: not published · FDA's orphan designation database turns away automated requests, so this app does not read it; search it by hand at the link

  Rule: Would be: an FDA orphan designation names the drug. Source: FDA orphan designations search
• FDA pediatric oncology approval: no · FDA's table lists no pediatric approval of Atogepant, Propranolol, Topiramate

  Rule: FDA's Pediatric Oncology Drug Approvals table names the drug. Source: FDA Pediatric Oncology Drug Approvals (content current as of 2026-03-03), 2026-11-12
• Registered studies open to children: yes · 173 interventional studies of Atogepant, Propranolol, Topiramate include patients under 18; 20 are recruiting, not yet recruiting or active

  Rule: The registry's age group includes Child (birth to 17 years), which also counts studies that set no minimum age. Source: ClinicalTrials.gov search, 2026-11-12

• Caveat: Site counts are not patients per country, and trials registered only outside ClinicalTrials.gov are not covered. Where the sites are is a fact about the record, not a judgement of its quality.
• Rare pediatric disease voucher: FDA, content current as of 29 Apr 2026: “As of February 3, 2026, enactment of the Consolidated Appropriations Act, 2026, the rare pediatric disease PRV program will sunset after September 30, 2029. FDA may not award any PRVs under this program after September 30, 2029.” Voucher sale prices are not shown here; they appear only as company-reported news. · FDA: Rare Pediatric Disease Designation and Priority Review Voucher Programs

• Not loaded on this app yet: Precedent approvals for target, modality and endpoint; accelerated-approval status. Source: Drugs@FDA and FDA accelerated-approval tables (ticket 30).

6. Can the sponsor finish?

• Sponsor: Mayo Clinic (academic or other) · ClinicalTrials.gov NCT06972056
• principal investigator: Todd J Schwedt, M.D., Mayo Clinic · Person page

• Not loaded on this app yet: Filed cash, quarterly spend and the runway arithmetic. Source: SEC XBRL company facts (ticket 37).
• Not loaded on this app yet: Sponsor's completed vs stopped oncology trials and results-reporting record. Source: Registry, by company (ticket 37).

What public data cannot tell you

Public records cannot show: sales forecasts; a probability of success for this asset; full deal terms and net prices; FDA designations and action dates before approval (shown only as company-reported); clinical holds unless the company disclosed them; manufacturing; patents on unapproved drugs; whether preclinical findings have been replicated.