Prognosis Following Discontinuation of OnabotulinumA Therapy in “Super‐responding” Chronic Migraine Patients

Abstract

Objective To determine whether the successful treatment of chronic migraine (CM) with onabotulinumA (BotoxA) may be followed by a continued respite from headache once therapy has been discontinued. Background The optimal duration of prophylactic therapy for migraine generally and for CM treated with BotoxA specifically is unknown. Methods We conducted a prospective cohort study evaluating a series of patients with CM at a university‐affiliated headache subspecialty clinic in Reno, Nevada, all of whom were treated according to a uniform protocol involving serial injections of BotoxA. We followed all positively responding patients who met our stopping rule for a minimum of 6 months after discontinuation of BotoxA, and we assessed the incidence of clinical worsening in that group. Results A total of 105/131 patients (80%) for whom complete follow‐up was available reported no clinical worsening or need to resume prophylactic therapy over the 6 months following discontinuation of BotoxA therapy. Patients with pre‐treatment baseline chronic daily headache (CDH) of greater than 6 months duration were more likely to report clinical deterioration within 6 months of stopping treatment, as compared to patients with CDH of less than 6 months. A greater number of BotoxA treatments required to achieve our stopping rule correlated with clinical deterioration within 6 months of stopping treatment. Conclusions In many CM patients who experience an especially positive response to serial BotoxA injection therapy, clinical improvement may be sustained for a period of at least 6 months following discontinuation of prophylactic therapy.

Wear‐Off of OnabotulinumtoxinA Effect Over the Treatment Interval in Chronic Migraine: A Retrospective Chart Review With Analysis of Headache Diaries

“…However, previous research on self‐reported wear‐off over ≥2 cycles suggested that ~20% of the patients experience repetitive wear‐off 17 . On the contrary, it has been reported that injections may successfully be delayed without exacerbation of headache in some patients, especially after the first year of treatment 27,28 . Reducing injection intervals to less than 12 weeks would be a possible strategy to counteract wear‐off in selected patients with repeated wear‐off.…”

OnabotulinumtoxinA in Migraine: A Review of the Literature and Factors Associated with Efficacy

“…In one prospective study, 49% of a cohort of 276 patients were withdrawn from OnaB-A after meeting the predefined criteria fewer than five MHD for two consecutive 12-week cycles and a MIDAS score of <10. Over six-months of follow-up, 80% of patients had no clinical worsening or need to resume preventative treatment [76]. In a smaller case series, OnaB-A was withdrawn in 54 patients who reverted to an episodic pattern, of whom 80% remained episodic migraine after six months [76].…”

Chronic Migraine and Medication Overuse Headache Worsening After OnabotulinumtoxinA Withdrawn Due to the Severe Acute Respiratory Syndrome-Coronavirus-2 Pandemic

“…On the contrary, Rothrock's group did not find, after 6 months, a worsening in migraine frequency in the group of "super-responders" to the BT-A, i.e., those patients achieving a migraine frequency and disability level for which prophylaxis is usually not indicated (16). The present study seems to confirm the results achieved by the first two ones (14,15), likely because of the higher rate of MOH sufferers in the analyzed sample if compared with the one of Rothrock's group (16). MOH increases CM patients' refractoriness to preventive treatments (3), and the analyzed sample was featured by a long CM history and a long MOH duration (Table 1).…”

“…Indeed, Guerzoni and collaborators found a general worsening of the patients' conditions (14), and, similarly, Cernuda-Morollòn and co-workers found out that 90% of patients reaching the year of treatment with the BT-A needed to continue it without delay to keep migraine frequency under control (15). On the contrary, Rothrock's group did not find, after 6 months, a worsening in migraine frequency in the group of "super-responders" to the BT-A, i.e., those patients achieving a migraine frequency and disability level for which prophylaxis is usually not indicated (16). The present study seems to confirm the results achieved by the first two ones (14,15), likely because of the higher rate of MOH sufferers in the analyzed sample if compared with the one of Rothrock's group (16).…”