Fred Cohen, MD: OnabotulinumtoxinA and CGRP Combination Treatment


The internal medicine resident physician at Montefiore Health System provided an overview of the study he and colleagues conducted on patients using onabotulinumtoxinA and CGRP agents in tandem.

“We looked at how patients were doing after the addition of a CGRP monoclonal antibody—this was done generally 2-3 months after they started—and they saw, on average, a further decrease of 5.6 headache days per month. When you combine it, this comes to a total decrease of 16.6 monthly headache days.”

Since the approval of the first members of the calcitonin gene-related peptide (CGRP) monoclonal antibody class for migraine prevention, a number of questions have been raised. Despite their efficacy, these agents often are not immediately available for every patient, with the disease needing to be refractory to other treatments first. However, their approval has nonetheless poised the inquiry as to how these medicines might interact in combination approaches.

Some small studies have been conducted to explore single agents in combination with acute treatments that also act on GCRP, such as the case-based work conducted by Mullin et al. on the combined use of rimegepant (Biohaven) and erenumab (Aimovig; Amgen) to treat refractory migraine.1 Now, additional data has been compiled by Fred Cohen, MD, internal medicine resident physician, Department of Medicine, Montefiore Health System, and colleagues on the use of onabotulinumtoxinA (Botox) in tandem with a CGRP in those who require additional preventive treatment.2

Presented at the American Headache Society (AHS) Virtual Annual Scientific Meeting on June 13, 2020, the data suggest that patients with chronic migraine receiving treatment with onabotulinumtoxinA can do so safely and effectively. To find out more about the study and its findings, NeurologyLive connected with Cohen.

For more coverage of AHS 2020, click here.


1. Mullin K, Kudrow D, Croop R, et al. Potential for treatment benefit of small molecule CGRP receptor antagonist plus monoclonal antibody in migraine therapy. Neurology. 2020;00:1-5. doi:10.1212/WNL.0000000000008944.

2. 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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