OnabotulinumtoxinA in Chronic Migraine: A Profile of Its Use

Frampton, James E.

doi:10.1007/s40263-020-00776-8

Cited by 9 publications

(4 citation statements)

References 47 publications

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“…cytochrome P450 enzymes, in contrast to oral preventives. Further, the duration of action is notably longer and the tolerability of onabotulinumtoxinA is generally better compared to oral drugs, especially considering the side effects of oral prophylactic drugs resulting in a low persistence [ 138 ].…”

Section: Discussionmentioning

confidence: 99%

The sense of stopping migraine prophylaxis

et al. 2023

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Introduction Migraine prophylactic therapy has changed over recent years with the development and approval of monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway. As new therapies emerged, leading headache societies have been providing guidelines on the initiation and escalation of such therapies. However, there is a lack of robust evidence looking at the duration of successful prophylaxis and the effects of therapy discontinuation. In this narrative review we explore both the biological and clinical rationale for prophylactic therapy discontinuation to provide a basis for clinical decision-making. Methods Three different literature search strategies were conducted for this narrative review. These include i) stopping rules in comorbidities of migraine in which overlapping preventives are prescribed, notably depression and epilepsy; ii) stopping rules of oral treatment and botox; iii) stopping rules of antibodies targeting the CGRP (receptor). Keywords were utilized in the following databases: Embase, Medline ALL, Web of Science Core collection, Cochran Central Register of Controlled Trials, and Google Scholar. Discussion Reasons to guide decision-making in stopping prophylactic migraine therapies include adverse events, efficacy failure, drug holiday following long-term administration, and patient-specific reasons. Certain guidelines contain both positive and negative stopping rules. Following withdrawal of migraine prophylaxis, migraine burden may return to pre-treatment level, remain unchanged, or lie somewhere in-between. The current suggestion to discontinue CGRP(-receptor) targeted mAbs after 6 to 12 months is based on expert opinion, as opposed to robust scientific evidence. Current guidelines advise the clinician to assess the success of CGRP(-receptor) targeted mAbs after three months. Based on excellent tolerability data and the absence of scientific data, we propose if no other reasons apply, to stop the use of mAbs when the number of migraine days decreases to four or fewer migraine days per month. There is a higher likelihood of developing side effects with oral migraine preventatives, and so we suggest stopping these drugs according to the national guidelines if they are well tolerated. Conclusion Translational and basic studies are warranted to investigate the long-term effects of a preventive drug after its discontinuation, starting from what is known about the biology of migraine. In addition, observational studies and, eventually, clinical trials focusing on the effect of discontinuation of migraine prophylactic therapies, are essential to substantiate evidence-based recommendations on stopping rules for both oral preventives and CGRP(-receptor) targeted therapies in migraine. Graphical Abstract

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Section: Discussionmentioning

confidence: 99%

The sense of stopping migraine prophylaxis

et al. 2023

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“…Consequently, one can argue that CGRP-mAbs may be effective in migraine patients with predominant involvement of the Aδ-fibers and high-threshold neurons, whereas migraine patients non-responsive to CGRP-mAbs could be characterized by a higher involvement of the C-fibers and/or different central trigeminovascular neurons ( 18 , 19 ). More recently, to provide rational clinical evidences of a combined therapy acting on the trigeminal nociceptive pathway (e.g., both Aδ-fibers and C-fibers), the synergistic effect of BTX-A and erenumab has been evaluated in a cohort of chronic migraine patients ( 11 , 20 ). In the study, a retrospective chart review of 78 patients investigated the therapeutic advantage in the MHDs and MMDs provided by the addition of erenumab to patients with chronic migraine who were receiving BTX-A.…”

Section: Discussionmentioning

confidence: 99%

Additive Interaction Between Onabotulinumtoxin-A and Erenumab in Patients With Refractory Migraine

et al. 2021

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In the last decade, notable progresses have been observed in chronic migraine preventive treatments. According to the European Headache Federation and national provisions, onabotulinumtoxin-A (BTX-A) and monoclonal antibodies acting on the pathway of calcitonin gene–related peptide (CGRP-mAbs) should not be administered in combination due to supposed superimposable mechanism of action and high costs. On the other hand, preclinical observations demonstrated that these therapeutic classes, although operating directly or indirectly on the CGRP pathway, act on different fibers. Specifically, the CGRP-mAbs prevent the activation of the Aδ-fibers, whereas BTX-A acts on C-fibers. Therefore, it can be argued that a combined therapy may provide an additive or synergistic effect on the trigeminal nociceptive pathway. In the present study, we report a case series of 10 patients with chronic migraine who experienced significant benefits with the combination of both erenumab and BTX-A compared to each therapeutic strategy alone. A reduction in frequency and intensity of headache attacks (although not statistically significant probably due to the low sample size) was observed in migraine patients treated with a combined therapy with BTX-A and erenumab compared to both BTX-A and erenumab alone. Moreover, the combined therapy with BTX-A and erenumab resulted in a statistically significant reduction in the symptomatic drug intake and in migraine-related disability probably related to a reduced necessity or also to a better responsiveness to rescue treatments. Present data suggest a remodulation of current provisions depriving patients of an effective therapeutic strategy in peculiar migraine endophenotypes.

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“…Performing at least three treatment cycles every 12 weeks is necessary to obtain a satisfactory clinical effect, and the continuation brings further clinical benefits [20]. Evidence from open-label real-world trials has proven the safety and effectiveness of treatment according to the PREEMPT protocol [21]. Recent observational studies indicate a clinical benefit even from several years of regular administration of OnaBoNT-A every 12 weeks [22].…”

Section: Discussionmentioning

confidence: 99%

Experience of treatment of chronic migraine with botulinum toxin type A among aesthetic medicine professionals in Poland

Boczarska-Jedynak¹

2023

Neurol Neurochir Pol.

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Introduction. This study aimed to evaluate the knowledge and standard of treatment of chronic migraine with botulinum toxin by Polish aesthetic medicine professionals.Rationale for the study. Onabotulinum toxin A injections are used as a preventive treatment for chronic migraine. Besides neurologists, healthcare professionals of multiple specialisms can offer this treatment. Aesthetic medicine professionals commonly use the treatment to extend the scope of their practice. This may bring about a situation wherein physicians with different levels of experience and training are providing botulinum toxin injections for chronic migraine. Material and methods.An online survey asking about patient qualification procedures, the level of adherence to the PREEMPT paradigm, product-, technique-, dosing-, and treatment intervals-related aspects of the treatment, efficacy evaluation practices and concerns about the use of botulinum toxin in chronic migraine was sent to 110 Polish physicians practicing aesthetic medicine.Results. The response rate was 73.6%. The results of the survey revealed multiple deviations from the current paradigm of treatment of chronic migraine with botulinum toxin, from improper patient qualification through treatment procedure to the evaluation of the efficacy. Only around one-third of professionals evaluated the observed effectiveness of therapy as very good. Most respondents wanted to expand their knowledge and skills in chronic migraine treatment. Conclusions.There is a considerable willingness among aesthetic medicine specialists to treat patients with chronic migraine with botulinum toxin. The current levels of knowledge and skills in this treatment are limited, and multiple physicians declared deviations from the diagnostic criteria and the therapeutic protocol. Transferring aesthetic medicine practices to neurology treatment is common and may result in a lack of effectiveness of treatment or even intensification of symptoms. An appropriate educational programme should be implemented for all physicians authorised to administer BoNT-A in Poland.

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OnabotulinumtoxinA in Chronic Migraine: A Profile of Its Use

Cited by 9 publications

References 47 publications

The sense of stopping migraine prophylaxis

The sense of stopping migraine prophylaxis

Additive Interaction Between Onabotulinumtoxin-A and Erenumab in Patients With Refractory Migraine

Experience of treatment of chronic migraine with botulinum toxin type A among aesthetic medicine professionals in Poland

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