Table 5.

Use of botulinum toxin A (BTXA) in chronic migraine

• BTXA should be administered according to the PREEMPT injection protocol, i.e. injecting 155 U–195 U to 31–39 sites every 12-weeks

• Treatment with BTXA should be stopped, if the patient does not respond to the first three treatment cycles.

• Patients treated with BTXA are defined as non-responders, if they have less than 30% reduction in headache days per month during treatment.

• Evaluate the response to continued treatment with BTXA on the basis of headache calendars by comparing the 4 weeks before and 4 weeks after each treatment cycle.

• Stop treatment in patients with a reduction to less than 10 headache days per month for 3 months (other factors such as headache intensity, disability and patient preferences should also be considered).

• Re-evaluate 4–5 months after stopping BTXA to secure that the patient has not returned to CM.

• In patients with chronic migraine and medication overuse, we suggest using BTXA, before or after withdrawal of acute medications, as second-line prophylactic treatment.

Adapted from Bendtsen et al., 2018 [7] with changes