Fred Cohen, MD: Combining CGRPs and OnabotulinumtoxinA for Migraine Prevention


The internal medicine resident physician at Montefiore Health System offers insight into the combined use of CGRP medications and Botox to optimize migraine prevention in patients who have inadequate response with Botox alone.

“We knew we had patients getting both, but it wasn’t ever carefully analyzed. One reason there is this lack of information is when they did the CGRP monoclonal antibody trials, they excluded patients that were getting Botox injections.”

Data presented by Fred Cohen, MD, internal medicine resident physician in the department of medicine at Montefiore Health System at the American Headache Society (AHS) Virtual Annual Scientific Meeting on June 13, 2020, suggest that patients with chronic migraine receiving treatment with onabotulinumtoxinA (Botox) who require additional preventive treatment can be given calcitonin gene-related peptide (CGRP) monoclonal antibody medications safely and effectively.

Ultimately, in a cohort of 153 patients treated with onabotulinumtoxinA, 66 continued to have 14.3 monthly headache days despite significant reductions from baseline headache days prior to treatment with onabotulinumtoxinA (baseline, 25.3 days; reduction, 10.9 days [43%]; P <.0001). The add-on of a CGRP therapy was associated with an additional decrease of 5.6 days, equating to an additional 22.3% reduction (95% CI, 4.5—6.7; P <.0001) in monthly headache days. Of the 153-patient study population, 88 (58%) were treated with erenumab (Aimvoig; Novartis), 51 (33%) were treated with galcanezumab (Emgality; Eli Lilly), and 14 (9%) were treated with fremanezumab (Ajovy; Teva).

To find out more about what prompted the study, what the population looked like, and how these data can be interpreted, NeurologyLive spoke with Cohen in an interview. He offered insight into the study’s reasoning as well as what research still needs to be done to analyze the combination use of these medicines.

For more coverage of AHS 2020, click here.


Cohen F, Armand C, Vollbracht S. Efficacy and Tolerability of CGRP Monoclonal Antibody Medications in Patients with Chronic Migraine Undergoing Treatment with OnabotulinumtoxinA. Headache. 2020;60(S1 suppl). 1-156. doi: 10.1111/head.13854

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