OnabotulinumtoxinA: A Review in the Prevention of Chronic Migraine

Abstract

An intramuscular formulation of onabotulinumtoxinA (onabotA; Botox^®) is currently the only therapy specifically approved for the prevention of headaches in adults with chronic migraine (CM) in the EU and North America. This article provides a narrative review of relevant data on the drug in this indication from an EU perspective. OnabotA was originally approved on the basis of pooled data from two phase III studies (PREEMPT 1 and 2). In these pivotal studies, injection of up to five cycles of onabotA (155-195 U/cycle) at 12-week intervals was generally well tolerated and effective in producing statistically significant and clinically meaningful improvements in headache symptoms, acute headache pain medication usage, headache impact and health-related quality of life in adults with CM, of whom approximately two-thirds were acute medication overusers and approximately one-third had failed to respond to ≥ 3 prior oral prophylactic therapies. More recently, the efficacy and tolerability of onabotA over a period of 1 year in the PREEMPT programme has been substantiated and extended by the results of a long-term phase IV study (COMPEL), in which patients received up to nine treatment cycles over a period of 2 years, and by findings from several real-world clinical practice studies from Europe, including the prospective multinational REPOSE and CM-PASS studies. In conclusion, the totality of evidence from clinical trials and real-world studies indicates that onabotA is an effective and generally well tolerated option for the prevention of CM that may be particularly useful for patients who have previously failed to respond to or are intolerant of commonly prescribed oral prophylactics.

Fig. 1

Proportion of onabotulinumtoxinA-treated patients who responded (with a ≥ 50% improvement from baseline in the headache symptom or impact assessment indicated) for the first time after treatment cycles 1, 2 and 3 in the pooled PREEMPT trials [52]. For each assessment, the maximum possible number of first-time responders in the cycle indicated is shown above the bar. HA headache, HIT-6 Headache Impact Test-6