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Am Fam Physician. 2019;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.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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