Combination Migraine Treatment: BOTOX + CGRP Monoclonal Antibodies 

OnabotulinumtoxinA (brand name BOTOX) and calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAb) (brand names Aimovig, Emgality, Ajovy) target different migraine pathways, therefore, combination treatment may provide additional effectiveness for the preventive treatment of chronic migraine (CM) than either treatment alone. A 2022 study collected real-world data to improve the understanding of the safety, tolerability, and effectiveness of adding a CGRP mAb to onabotulinumtoxinA treatment for the preventive treatment of CM. The effectiveness of combination preventive treatment was assessed by the reduction in monthly headache days (MHD). Electronic medical records were collected for 192 patients, of which 148 met eligibility criteria and were included for analysis. After ~12 months of continuous combination treatment, MHD were reduced by 4.6 days/month and 34.9% of patients achieved ≥50% MHD reduction. Most common side effects were constipation and injection site reactions. No serious adverse events were reported. In this real-world study, onabotulinumtoxinA was effective at reducing monthly headache days and the addition of a CGRP mAb was safe, well-tolerated and associated with reductions in monthly headache days for those who stayed on the combination treatment. Of those who discontinued, the majority reported lack of insurance coverage as a reason.  
At MCHN, we have seen the effectiveness of Botox and CGRP mABs as stand-alone treatments. We have also seen a number of patients where either Botox or CGRP did not provide enough control for our patients to live productive lives. In some cases, the combination of Botox and CGRP provided the results we needed. If you continue to struggle with migraines, please call MCHN to schedule an appointment to discuss. Be well. 

–Alice Wong, NP 

Reference: Mechtler L, Saikali N, McVige J, Hughes O, Traut A, Adams AM. Real-World Evidence for the Safety and Efficacy of CGRP Monoclonal Antibody Therapy Added to OnabotulinumtoxinA Treatment for Migraine Prevention in Adult Patients With Chronic Migraine. Front Neurol. 2022 Jan 6;12:788159. doi: 10.3389/fneur.2021.788159. PMID: 35069416; PMCID: PMC8770868.