Letters to the Editor

OnabotulinumtoxinA Injections for Chronic Migraine Prophylaxis


Am Fam Physician. 2019 Aug 15;100(4):198.

Original Article: Migraine Headache Prophylaxis

Issue Date: January 1, 2019

See additional reader comments at: https://www.aafp.org/afp/2019/0101/p17.html

To the Editor: We appreciated this article on migraine headache prophylaxis from Drs. Ha and Gonzalez. Because of the prevalence of migraine headaches, we would like to elaborate on the role of onabotulinumtoxinA (Botox) injections for chronic migraines. This is an office-based procedure that can be performed by family physicians and can provide great relief to patients. Largely because of cost, it should be reserved for patients who have chronic migraines (not episodic migraines or tension-type headaches) and who have had no success with daily prophylactic therapies.

According to the American Academy of Neurology, onabotulinumtoxinA should be offered to patients with chronic migraines, with the goal of increasing the number of headache-free days and reducing impact on health-related quality of life.1 These recommendations are based on two randomized trials that showed a statistically significant decrease in the frequency of headache days.2,3 Since then, other studies have demonstrated its tolerability, safety, and effectiveness in the treatment of chronic migraines.4,5 One study also demonstrated the cost-effectiveness of the injections through a reduction in urgent care/emergency department visits and hospitalizations.6

The onabotulinumtoxinA injection procedure comprises superficial injections into 31 mapped sites. They are generally well-tolerated, and patients can return to normal activity the same day. The most common adverse effects reported are neck pain, muscle weakness, eyelid ptosis, and injection-site pain. This treatment is a relatively easy in-office primary care procedure that can provide significant pain relief to patients with chronic migraine headaches.

Author disclosure: No relevant financial affiliations.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, Department of the Air Force, Department of Defense, or the U.S. government.


show all references

1. Simpson DM, Hallett M, Ashman EJ, et al. Practice guideline update summary: botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2016;86(19):1818–1826....

2. Aurora SK, Dodick DW, Turkel CC, et al.; PREEMPT 1 Chronic Migraine Study Group. OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia. 2010;30(7):793–803.

3. Diener HC, Dodick DW, Aurora SK, et al.; PREEMPT 2 Chronic Migraine Study Group. OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial. Cephalalgia. 2010;30(7):804–814.

4. Frampton JE, Silberstein S. OnabotulinumtoxinA: a review in the prevention of chronic migraine. Drugs. 2018;78(5):589–600.

5. Escher CM, Paracka L, Dressler D, et al. Botulinum toxin in the management of chronic migraine: clinical evidence and experience. Ther Adv Neurol Disord. 2017;10(2):127–135.

6. Rothrock JF, Bloudek LM, Houle TT, et al. Real-world economic impact of onabotulinumtoxinA in patients with chronic migraine. Headache. 2014;54(10):1565–1573.

This letter was sent to the authors of “Migraine Headache Prophylaxis,” who declined to reply.

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