OnabotulinumtoxinA Effective in Hard-to-Treat Migraine

TOPLINEOnabotulinumtoxinA (BoNT-A) reduced the overall headache burden and resolved medication-overuse headache (MOH) in patients with chronic migraine who had not responded to at least two prior oral preventive treatments. A positive family history of migraine and at least four prior preventive medication failures were independent predictors of a poorer treatment response, although clinical predictors remained weak.METHODOLOGYResearchers conducted a retrospective study to assess the real-world clinical efficacy of BoNT-A in patients with chronic migraine participating in a national reimbursement programme and to identify potential clinical predictors of treatment response.The study included 479 patients with chronic migraine (mean age, 43.6 years; 88.9% women) who had not responded to at least two prior oral preventive therapies and received BoNT-A treatment across 12 tertiary headache centres. All patients received BoNT-A injections across 39 injection sites at 3-month intervals for 9 months.The primary efficacy endpoint was at least a 50% reduction in monthly headache days (MHDs) after 9 months, with patients classified as responders (a reduction of at least 50% in MHDs), partial responders (a reduction of 25%-49% in MHDs), and non-responders (a reduction of less than 25% in MHDs).Other outcomes included monthly migraine days (MMDs), acute medication days (AMDs), the Migraine Disability Assessment (MIDAS) score, and MOH.TAKEAWAYAfter 9 months of treatment, mean MHDs reduced by 5.9 days, mean MMDs reduced by 4.7 days, and the mean MIDAS score reduced by 52.7 points.Median MHDs, MMDs, and AMDs declined from 18, 15, and 16 days at baseline to 14, 11, and 11 days at 9 months, respectively (P < .01 for all), and the median MIDAS score fell from 99 to 45 points (P < .01).Overall, 27.3% of patients achieved at least a 50% reduction in MHDs and 23.2% achieved a 25%-49% reduction in MHDs after 9 months of treatment; 41.6% of patients no longer met the criteria for MOH at 9 months.In multivariable analysis, a positive family history of migraine (odds ratio [OR], 0.55; P = .005) and at least four prior preventive treatment failures (OR, 0.61; P = .042) were significantly associated with a poorer treatment response, although these clinical factors lacked sufficient power to predict treatment outcomes (area under the curve, 0.605).IN PRACTICE"A crucial observation from our study is the negative impact of multiple prior treatment failures on the efficacy of BoNT-A. This finding highlights a significant clinical and systemic challenge: the delayed initiation of advanced migraine therapies, which may limit the ultimate success of the treatment," the authors wrote.SOURCEThis study was led by Marta Waliszewska-Prosół, MD, PhD, Wroclaw Medical University, Wrocław, Poland. It was published online on August 25, 2026, in Therapeutic Advances in Neurological Disorders.LIMITATIONSThe retrospective observational design may have introduced selection bias or incomplete data. Because the study was conducted within a strict national reimbursement framework, the findings may have limited generalisability to other healthcare settings. The 9-month follow-up period may have underestimated long-term effectiveness.DISCLOSURESThe study was supported by Wroclaw Medical University. Some authors declared receiving honoraria or honoraria for lectures or speaker activities or serving on advisory boards of different pharmaceutical companies.This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.