What is changing in chronic migraine treatment? An algorithm for onabotulinumtoxinA treatment by the Italian chronic migraine group

Expert Rev Neurother. 2020 Dec;20(12):1275-1286. doi: 10.1080/14737175.2020.1825077. Epub 2020 Sep 30.


Introduction: OnabotulinumtoxinA (OBT-A) and monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway are two of the few treatments that ameliorate chronic migraine (CM) in randomized controlled trials and real-life studies. Separate clinical practice guidelines have been developed for the management of CM with OBT-A or CGRP-targeting mAbs.

Areas covered: Considering the concomitant availability of OBT-A and CGRP-targeting mAbs as therapeutic treatment options, Italian migraine experts reviewed the evidence supporting the efficacy of OBT-A and CGRP-targeting mAbs in CM in order to rationalize the management of CM patients treated with OBT-A. Experts addressed everyday practice needs to shape the optimal pharmacological management by balancing adherence to regulatory indications, ethical considerations, and clinical expertise. Considering the remarkable challenge of improving the health and quality of life of patients with CM, even partial improvements may be clinically meaningful, particularly for those who are resistant or intolerant to oral migraine treatments.

Expert opinion: In this collaborative effort, we propose a treatment algorithm that integrates the relevant aspects of managing patients with CM to provide ready-to-use practical guidance regarding the appropriate use of OBT-A.

Keywords: Chronic migraine; GCRP-targeting monoclonal antibodies; calcitonin gene-related peptide; migraine prophylaxis; onabotulinumtoxinA; treatment algorithm.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Algorithms*
  • Botulinum Toxins, Type A / therapeutic use*
  • Chronic Disease / drug therapy*
  • Humans
  • Italy
  • Migraine Disorders / drug therapy*
  • Neuromuscular Agents / therapeutic use*


  • Neuromuscular Agents
  • Botulinum Toxins, Type A
  • onabotulinum toxin A