Updated Treatment Guidelines for the Use of Botulinum Toxin in Spasticity, Headache

Treatment of chronic, but not episodic migraine with botulinum toxin has been added to the treatment guidelines.

VANCOUVER, British Columbia – After reviewing recent research, the American Academy of Neurology (AAN) has updated its 2008 guidelines on the use of botulinum toxin for the treatment of spasticity, cervical dystonia, blepharospasm, and now chronic migraine.

The guidelines, which were presented at the 2016 annual meeting of the American Academy of Neurology and published in Neurology, cover the use of all 4 drug formulations: abobotulinumtoxinA, incobotulinumtoxinA, onabotulinumtoxinA, and rimabotulinumtoxinB.

Botulinum toxin as a whole helps to reduce muscle contraction and transmission of pain signals, and has been deemed generally safe and effective for the treatment of spasticity in adults, cervical dystonia, blepharospasm, and chronic migraine. The different formulations are not interchangeable, however. In this review, efficacy of botulinum toxin was based on symptomatic control, as there is no evidence indicating disease modification.

In total, the AAN guidelines development subcommittee reviewed 23 research articles on blepharospasm, 23 on cervical dystonia, 86 on spasticity, and 28 on headache.

Based on the available literature, the following formulations have been recommended.


  • OnabotulinumtoxinA (onaBoNT-A) and incobotulinumtoxinA (incoBoNT-A) are probably effective (Level B evidence).
  • AbobotulinumtoxinA (aboBoNT-A) is possibly effective (Level C).

Cervical Dystonia

  • AboBoNT-A and rimabotulinumtoxinB (rimaBoNT-B) are effective (Level A).
  • OnaBoNT-A and incoBoNT-A are probably effective (Level B).

Spasticity in Adults

  • AboBoNT-A, incoBoNT-A, and onaBoNT-A are effective (Level A).
  • RimaBoNT-B is probably effective for upper limb spasticity (Level B).
  • AboBoNT-A and onaBoNT-A are effective for lower limb spasticity (Level A).


  • OnaBoNT-A is effective for increase in headache-free days (Level A) and probably effective for improvement of quality of life (Level B) in chronic migraine.
  • OnaBoNT-A is ineffective for episodic migraine (Level A) and probably ineffective for chronic tension-type headache (Level B).

While the 2008 guidelines also covered disorders including essential tremor and hemifacial spasm, no new evidence for these disorders was available for review and therefore was not included in the guidelines update.

The guidelines were supported by the American Academy of Neurology and have been endorsed by the American Association of Neuromuscular & Electrodiagnostic Medicine and the American Society of Plastic Surgeons.

Click here for more coverage from the 68th Annual Meeting of the American Academy of Neurology, April 15-21, 2016, in Vancouver, British Columbia, Canada.


Simpson D, 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. [Epub ahead of print] doi: 10.1212/WNL.0000000000002560.