Dual Treatment May Boost Efficacy in Chronic Migraine

For patients with chronic migraine, combination therapy with anti-CGRP monoclonal antibodies and onabotulinumtoxinA may be more effective than monotherapy, possibly owing to the synergistic mechanism of action of the two agents, a new study suggests.

"People with chronic migraine may be the toughest to treat. They have the greatest disability, and often insurance companies would prefer monotherapy, but in these patients, sometimes using a multifaceted approach and using different drugs that target different pathophysiologies of migraine can probably provide greater benefit in terms of reducing the frequency and severity of the headaches," study investigator MaryAnn Mays, MD, staff neurologist at the Headache and Facial Pain Clinic in the Neurologic Institute, Cleveland Clinic, Cleveland, Ohio, told Medscape Medical News.

The findings were presented at the American Headache Society (AHS) Annual Meeting 2023.

Fewer Migraine Days

OnabotulinumtodxinA (onabot) has been shown to selectively inhibit unmyelinated C-fibers but not Aδ-meningeal nociceptors. Anti-CGRP mAb therapies have been shown to prevent the activation of Aδ fibers but not C-fibers, said Mays.

For the study, the investigators reviewed the electronic medical records of 194 patients who had been concurrently treated with anti-CGRP mAbs and onabot. Most (86.6%) were women; ages ranged from 36 to 65 years, and at baseline, they had been having an average of 28 (+4.6) monthly migraine days (MMDs).

The number of MMDs were assessed at two periods: 3 months after monotherapy with an anti-CGRP mAb or onabot injections, and 3 months after combined therapy.

Monotherapy reduced the average number of MMDs from 28 to 18.6, for a reduction of 9.4 days (P > .0001).

After initiation of combined therapy, the average number of MMDs decreased further, from 18.6 MMDs to 12.1 MMDs (P > .0001).

In all, the combination of onabot and anti-CGRP mAbs resulted in a total MMD reduction of 15.8 (P > .0001).

In addition, most patients (68%) reported a 50% or greater reduction in MMDs, and 46.4% reported a 75% or greater reduction.

Great News for Patients

Commenting for Medscape Medical News, Rashmi B. Halker Singh, MD, associate professor of neurology at Mayo Clinic, Scottsdale, Arizona, said the study findings "support what we see in clinical practice and what we suspected from preclinical data."

Single-agent treatment is not sufficient for many patients. Data confirming the benefit of dual therapy will provide more evidence to insurance companies of the need for coverage.

"We have lots of individuals for whom single treatment is not sufficient and who need this combination of treatment, and it is often denied by insurance. There are preclinical data suggesting synergy, but insurance says it is experimental, so the claims get denied. This leaves patients having to choose which drug they want to continue with, and that's really heartbreaking," Halker Singh said.

The importance of this study is that it adds more data to support evidence-based therapies for migraine and to help patients get the treatment they need, she added.

Mays reports financial relationships with AbbVie, Amgen, and Teva. Halker Singh reports no relevant financial relationships.

American Headache Society (AHS) Annual Meeting 2023: Abstract P-183. Presented June 17, 2023.

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Cite this: Dual Treatment May Boost Efficacy in Chronic Migraine - Medscape - Jun 29, 2023.