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The Changing Landscape of Preventive Treatment of Migraine - Episode 10

OnabotulinumtoxinA for Preventative Migraine Treatment

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Stephanie J. Nahas, MD, MSEd, FAHS, FAAN, provides an overview of the use of onabotulinumtoxinA as a preventive migraine treatment.

Jessica Ailani, MD: Stephanie, while I have you and you mentioned onabotulinumtoxinA, it is funny because even though it’s onabotulinumtoxin, Andy mentioned earlier that it is really considered an older treatment now. I had a patient who said to me the other day that her friends were all telling her about some of the new monoclonal antibodies, but she has been on onabotulinumtoxin, one of the “old drugs” forever and she’ll remain on it because it’s doing well. I looked at her and I was like, huh. I don’t really think of onabotulinumtoxin as one of the old drugs but OK, so be it, it is pretty old now.

How do you find onabotulinumtoxin working in your clinic? I know you have still quite a few patients on it, how well do you think it’s working in comparison to say some of the newer treatment options? We’ve talked a little bit, Chris mentioned its use in the concomitant therapy with the CGRP [calcitonin gene-related peptide antibodies] monoclonal antibodies and some science showing that they can be combined. Do you find that it’s a tolerable treatment? Really, how are you using it in clinical practice today?

Stephanie J. Nahas, MD, MSEd, FAHS, FAAN: Well, of course, it’s FDA approved only for chronic migraine, 15 days a month or more for at least 3 months, 8 of those days have to be migraine, “blah, blah, blah.” So you do have to carve out a specialized population of patients who are eligible for it. Thankfully for us, that’s most of what we see. We have a lot of patients that are treated with it, and like with any case, how you measure success varies from person to person. We have plenty of patients who had constant 8 to 10 out of 10 headache all the time and debilitating migraine-associated symptoms. We get them started on “onabot” which I’ll use for short for the name because onabotulinumtoxinA is a bit of a mouthful, they still never become pain free, but they go from that 8 to 10 every day down to a 3 to 5 every day, and there are many days when their associated symptoms are really not there. Now, in the clinical trials that would be a treatment failure but for that patient that’s a whopping success.

We’ve seen a lot of patients also who have had “onabot” elsewhere and they say it didn’t work. And I like to ask more details, “Well, what dose were you getting? How often were you getting it? How many times did you try it?” And I hear the craziest things, which sometimes I can verify with some office notes that they got like 2 injections on each side of their forehead and that’s it or they were going 4 and 5 months in between their treatments. So the dosing has to be correct. You have the ability and your own clinical creativity to go a little bit beyond the label. The label dictates that there are prespecified sites. You have to use this dose and only this dose, but there is no one-size-fits-all. Some patients actually do better with lower doses. Most of our patients need higher doses and they need some creative placement of where those injections go.

I would say that I have the sense that most of our patients who start on onabotulinumtoxinA in our practice wind up staying on it. Some of them can give up some of their other preventive medications, some of them can’t. We have a lot of patients who we try to do this juggling act of rational polypharmacy, but what has made this rational polypharmacy easier is not only having a treatment like onabotulinumtoxinA but also having the monoclonal antibodies, which can be synergistic together. And we’ve seen it. We’re looking at our own clinic data to prove what other centers have already proven, that when you combine the 2 together it’s like Reese’s Peanut Butter Cups. You get 2 great things that are great on their own, you combine them together and you get some amount of synergy and a lot of patient satisfaction.

Jessica Ailani, MD: I was thinking PB&J but there’s nothing better than Reese’s Peanut Butter Cups, so that’s a pretty good analogy there. I almost want to see, Andy, do you have any controversial comments about this? Because I feel like this is something you might argue.

Andrew C. Charles, MD: No. I’ve been much more skeptical than others in the field about Botox in the past. I’ll say that I’ve certainly come around and appreciate that there’s a subset of patients who do spectacularly well with that. The one issue that actually comes up with other preventive therapies as well, even some of the new ones, is the end of the dose wearing off. That was another variable Steph mentioned. Some of the other variables like how much you give and where you put it, but then the other thing is you’re sort of stuck by payers with this dosing interval that may be too long for some individuals. So that is something that we run into, that comes 2 weeks before their next dose and they start having an increased frequency of attacks again. It’s not particularly controversial, it’s just one of the other issues that we deal with.

To the point of combining with some of the monoclonal antibodies, there, unfortunately, for me or our practice, is that situation that Steph brought up where if you put it out there, it raises hope but it’s so hard to get payers to approve both. It’s a real challenge, so I almost don’t even want to think about it even though I should but it’s just literally an impossibility for people to actually get it covered.

Jessica Ailani, MD: These are good points. I think depending regionally where you are there are definitely coverage issues. I think it’s a constant struggle for a portion of patients with the wear-off and we do see it with onabotulinumtoxin, which sometimes you can treat with trigger point injections or occipital nerve blocks or just nerve blocks in general. But sometimes that’s not effective for those patients. There is a study actually that used erenumab [Aimovig] for wear-off effect trying to get the dosing just right and showed efficacy. But I will tell you in the long run it doesn’t work because the dosing interval just starts to end up where they ended up not lining up properly, and, at some point, they’re wearing off from everything. It seems like it should work, but at some point over the course of a year they’re wearing off from everything at the same time and it becomes quite a disaster.

Jessica Ailani, MD: Thank you to our audience for watching this Neurology Live® Peer Exchange. I hope that you’ve enjoyed watching this program as much as we’ve enjoyed spending this time together. If you have enjoyed this content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox.

Transcript edited for clarity.