Adding CGRP Antibodies to Botox Improves Chronic Migraine Control | Research

The takeaway

Adding CGRP monoclonal antibody therapy to ongoing onabotulinumtoxinA (Botox) treatment provided additional clinically meaningful migraine reduction in chronic migraine patients in a real-world clinical setting.

3.5-4.0 fewer monthly headache days
Additional reduction when CGRP mAbs were added to ongoing onabotulinumtoxinA therapy

What the researchers found

Combination of CGRP mAbs with onabotulinumtoxinA reduced monthly headache days by an additional 3.5-4.0 beyond Botox alone, with 45.1% achieving meaningful disability improvement.

Why it matters

Many chronic migraine patients don't achieve adequate relief from a single preventive therapy. This real-world evidence supports combining two different mechanism-based treatments for better outcomes.

The numbers in context

257 patients; 21.5 MHDs pre-Botox; 12.1 pre-CGRP mAb; 3.5-4 MHD reduction; 45.1% MIDAS response; 78% erenumab; 28% adverse events

How the study worked

Retrospective longitudinal chart review of 257 adults with chronic migraine at one clinical site, tracking outcomes at 3, 6, 9, and 12 months after adding CGRP mAb to ongoing Botox therapy.

Who was studied

Chronic migraine adults on stable onabotulinumtoxinA (mean age 50, 82% women)

What this study cannot tell us

Retrospective design without a control group. Single clinical site. Predominantly erenumab (78%) with limited data on other mAbs. No randomization or blinding.

How to read the evidence

Real-world retrospective study with a large sample (n=257) but no control group. Provides moderate-quality evidence supporting combination therapy.

When this study was published

Published in 2021, when CGRP antibodies were relatively new additions to the migraine treatment landscape.

The bigger picture

Chronic migraine is a debilitating condition that often requires multiple treatments. This study provides real-world evidence supporting a dual-mechanism approach, combining Botox (which works on nerve signaling) with CGRP antibodies (which block the pain peptide pathway) for patients who need additional relief.

Questions still open

Would a randomized controlled trial confirm these combination benefits?
Are there specific patient characteristics that predict better response to combination therapy?
Is there a difference in combination efficacy between the different CGRP antibodies?

Common questions

Can you take Botox and CGRP antibodies together for migraines?

Yes. This study of 257 patients found that adding a CGRP antibody to ongoing Botox treatment was well-tolerated and provided additional headache reduction of 3.5-4.0 fewer monthly headache days beyond what Botox alone achieved.

What were the side effects of combining these treatments?

The combination was generally well-tolerated. Constipation was the most common side effect (9% of patients). Patients were more likely to stop the CGRP antibody (23%) than Botox (3%) during the study period. No new or unexpected safety issues were identified.

Read the original research

Real-World Evidence for Control of Chronic Migraine Patients Receiving CGRP Monoclonal Antibody Therapy Added to OnabotulinumtoxinA: A Retrospective Chart Review.

Pain and therapy, 10(2), 809-826

View on PubMed ↗Publisher’s paper ↗

Citation

Blumenfeld, Andrew M; Frishberg, Benjamin M; Schim, Jack D; Iannone, Ashley; Schneider, Gary; Yedigarova, Larisa; Manack Adams, Aubrey. (2021). Real-World Evidence for Control of Chronic Migraine Patients Receiving CGRP Monoclonal Antibody Therapy Added to OnabotulinumtoxinA: A Retrospective Chart Review.. Pain and therapy, 10(2), 809-826. https://doi.org/10.1007/s40122-021-00264-x