In a consensus statement by the European Headache Federation published in the Journal of Headache and Pain, researchers and pain experts formulated guidelines for the use of onabotulinumtoxinA for the management of chronic migraine. The guideline includes recommendations on onabotulinumtoxinA dosing, treatment initiation, and termination.

An expert panel was convened by the European Headache Federation to address key clinical questions regarding the use of onabotulinumtoxinA for the management of chronic migraine. Answers to these questions were compiled into a clinical guideline, which was based on available clinical evidence and the panel’s clinical experience using the medication for chronic pain conditions.

According to a high quality level of evidence, onabotulinumtoxinA appears to be effective and well tolerated. It is recommended that patients with chronic migraine who have not shown responsiveness to 2 to 3 prophylactic migraine medications be considered for this therapy. 

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Detoxification should be initiated in patients with chronic migraine and a recent history of medication overuse before initiating onabotulinumtoxinA therapy. The injection protocol used in the PREEMPT trial ( identifier: NCT00156910) should be followed (ie, 155-196 units injected to 31-39 sites every 12 weeks). Patients reporting a <30% reduction in headache days/month during onabotulinumtoxinA treatment are considered nonresponders.

Physicians should evaluate therapy response throughout treatment using headache calendars and should compare headache frequency during the 4 weeks before and after each therapy cycle. Treatment should be halted in patients with <10 headache days/month during a 3-month period. Headaches should be reassessed approximately 4 to 5 months after treatment termination.

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”The experts in the present panel are confident that onabotulinumtoxinA has an important role in the management of [chronic migraine] provided that the recommendations in this guideline are followed. However, only the first of the clinical questions in this guideline, regarding efficacy and tolerability of onabotulinumtoxinA, could be answered on the basis of scientific evidence,” concluded the guideline authors.


Bendtsen L, Sacco S, Ashina M, et al. Guideline on the use of onabotulinumtoxinA in chronic migraine: a consensus statement from the European Headache Federation. J Headache Pain. 2018;19(1):91.

This article originally appeared on Clinical Pain Advisor