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Welcome to Neuroscience Pearls: A publication from the UW Medicine Neurosciences Institute. Our goal is to provide useful information pertinent to your practice. Here we bring you key points related to Botox® treatment for chronic migraine.

Richard G. Ellenbogen, MD, Professor and Chairman, Department of Neurological Surgery, Director, UW Neurosciences Institute
Bruce R. Ransom, MD, PhD, Professor and Chair, Department of Neurology, Adjunct Professor, Department of Physiology and Biophysics, Co-Director, UW Neurosciences Institute
Contributing Authors:
Natalia Murinova, MD, Clinical Assistant Professor, UW Department of Neurology, Director, Neurology Headache Clinic
Daniel Krashin, MD, Director, Chronic Fatigue Clinic at UW, Clinical Lead of the Outpatient Pain Clinic at Harborview Medical Center, Clinical Assistant Professor of Psychiatry
Jenna Kanter, MD, Clinical Assistant Professor, Department of Neurology

The term Chronic Migraine (CM) is defined by International Heachache Society criteria (ICHD-3 beta) as a "Headache occurring on 15 or more days per month for more than 3 months, which has the features of migraine headache on at least 8 days per month." 1 The Food and Drug Administration (FDA) uses broader criteria, and defines CM for BOTOX® treatment as patients with headaches on at least 15 days per month for 3 months; it does not require migraine features.

In the USA, the prevalence of CM is nearly 1%.2 This translates to ~ 3.3 million CM patients.

The first step in assessing a headache patient is to determine his/her specific diagnosis by careful history taking. CM is diagnosed using the International Headache Society criteria (ICHD-3)1. It is important to exclude secondary headaches that can mimic migraine.


  1. CM is difficult to treat and requires a multidisciplinary and multimodal approach, as patients suffering from CM are often refractory to pharmacotherapy. Moreover, they are often discouraged and can be less compliant with any therapy.
  2. The only two pharmacological treatments that have been shown to be effective in placebo-controlled randomized trials for CM are topiramate and BOTOX® (onabotulinum toxinA). BOTOX® is FDA-approved medication for prevention of CM.
  3. Non-pharmacological treatments include lifestyle modification, supplements, physical therapy, acupuncture and behavioral treatments, and are essential for significant long-term improvement.

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August 2015 | Volume 3: Issue 2