Botulinum Toxin Therapy for Chronic Migraine

Indications and Contraindications

• The American College of Physicians suggests onabotulinumtoxinA injection for the prevention of chronic migraine (weak recommendation) 5, 4
• The VA/DoD Clinical Practice Guideline suggests against using onabotulinumtoxinA for episodic migraine (weak recommendation against) 5, 4

Assessment and Evaluation

• The Mayo Clinic recommends continuation of onabotulinumtoxinA therapy is considered medically necessary for chronic migraine prophylaxis only when the patient has achieved or maintained a reduction in monthly headache frequency since starting therapy 1, 2, 3
• Documentation of headache frequency before and after Botox treatment is essential, as stated by the American Academy of Neurology 1, 2
• Patient has tried gabapentin and topiramate as preventive treatments, with guidelines suggesting against gabapentin for migraine prevention (weak recommendation against) and topiramate suggested for prevention of chronic migraine (weak recommendation for) 4, 1

Treatment Response and Alternative Approaches

• Research shows that treatment response should be evaluated approximately 2 weeks after initial injection, according to the American Urological Association 7
• If Botox efficacy cannot be determined, consider monoclonal antibodies targeting CGRP (erenumab, fremanezumab, galcanezumab) which have strong recommendations for both chronic and episodic migraine, as recommended by the American Headache Society 4, 6
• Topiramate is suggested for prevention of chronic migraine (weak recommendation for), as stated by the American Academy of Neurology 4, 1