Patients and clinicians agreed that head-to-head trials comparing CGRP antibodies to Botox should be the top chronic migraine research priority.
CGRP vs Botox: #1 priorityBoth patients and clinicians agreed that comparing these two leading preventive treatments should be the top research focus
What the researchers found
Using nominal group technique (a structured consensus method), the stakeholders identified their research priorities:
1. Top priority: Comparing CGRP monoclonal antibodies to onabotulinumtoxinA (Botox)
2. High priority: Candesartan vs placebo
3. High priority: Flunarizine vs placebo
4. Also discussed: Combining CGRP antibodies with other medications
The group noted that despite multiple available chronic migraine preventives, high-quality head-to-head randomized evidence is scarce. Most drugs were tested only against placebo, making it hard for clinicians and patients to choose between options.
Why it matters
Chronic migraine affects about 2% of the global population. Multiple preventive treatments exist (Botox, CGRP antibodies, topiramate, amitriptyline, candesartan, flunarizine) but doctors have little evidence to guide which to try first. This patient-clinician consensus highlights the most urgent evidence gaps from the perspective of those most affected.
The numbers in context
- 8 chronic migraine patients participated
- 11 healthcare professionals participated
- Top priority: CGRP mAbs vs onabotulinumtoxinA
- Drug priorities vs placebo: candesartan and flunarizine
- Chronic migraine: headaches on ≥15 days per month
How the study worked
Online consensus workshop using nominal group technique, a structured approach where participants independently generate ideas, share them, discuss, and rank priorities through voting. Eight people with chronic migraine and eleven healthcare professionals participated.
Who was studied
8 chronic migraine patients and 11 healthcare professionals in a UK-based online consensus workshop
What this study cannot tell us
Small sample size (19 participants). UK-based, so priorities may differ in other healthcare systems. Nominal group technique produces consensus but may not represent the full range of patient and clinician perspectives. The workshop format limits deep exploration of any single topic. Funding for the identified trials is not guaranteed.
How to read the evidence
Rated not applicable: this is a consensus workshop identifying research priorities, not a study measuring treatment effects.
When this study was published
Published in 2024. Reflects current clinical uncertainty about treatment sequencing for chronic migraine.
The bigger picture
Multiple preventive treatments exist for chronic migraine but doctors lack evidence on which to try first. Patient-clinician consensus on research priorities helps focus limited research resources on the most impactful questions.
Questions still open
- Why haven't CGRP antibodies been compared head-to-head with Botox yet?
- Would research priorities differ in other countries?
Common questions
Which is better for chronic migraine: CGRP drugs or Botox?
Why is this question so important?
Read the original research
Research priorities for randomised controlled trials in chronic migraine preventive medication: A stakeholder consensus workshop.
NIHR open research, 4, 16
Citation
Rees, Sophie; Cooklin, Andrew; Duncan, Callum; Matharu, Manjit; Naghdi, Seyran; Underwood, Martin; Mistry, Hema. (2024). Research priorities for randomised controlled trials in chronic migraine preventive medication: A stakeholder consensus workshop.. NIHR open research, 4, 16. https://doi.org/10.3310/nihropenres.13548.2