Association Between Personality Traits and Onabotulinumtoxin a Response in Patients With Chronic Migraine

Alicia Gonzalez-Martinez, MD; Eva Rodríguez Vázquez, MD; Henar de la Red Gallego, MD; David García-Azorín, MD; Mercedes Gallego de La Sacristana, MD; Ángel Luis Guerrero Peral, MD, PhD; Ana Beatriz Gago-Veiga, MD, PhD


Headache. 2020;60(1):153-161. 

In This Article

Abstract and Introduction


Objective: The aim of this study was to analyze the potential association between personality traits and onabotulinumtoxin A (onabotA) response in patients with chronic migraine (CM).

Background: Previous studies from a categorial perspective show that patients with CM have anxious or obsessive personality according to the Salamanca screening test. However, the influence of personality traits in onabotA response in patients with CM has not yet been studied. We hypothesize that cluster C personality traits may be associated with non-response to onabotA.

Methods: This case-control observational study includes patients with CM who received at least 2 treatment cycles of onabotA in 2 headache units between January and May 2018. onabotA response was defined as a reduction of at least 50% in the number of monthly migraine days. Personality traits were evaluated using the Salamanca questionnaire, a validated categorial inventory assessing 11 personality traits.

Results: One hundred and twelve patients, 100/112 (89.6%) females, mean age (standard deviation): 43 (11) years, were recruited. 96/112 (85.7%) achieved response to onabotA. Dependent trait was significantly associated with non-response to onabotA (P = .008; OR: 0.223 [95%CI: 0.074 to 0.675]). Significant association with other personality traits or confounders was not found.

Conclusions: To the best of our knowledge, this is the first study showing personality traits may predict onabotA response in patients with CM. The presence of dependent personality trait in patients with CM is associated with non-response to onabotA.


The relationship between migraine and personality has been a topic of interest since the second half of the twentieth century. During that time, several studies have been performed focusing on personality patterns in patients with migraine and other primary headaches.[1–3] Migraine affects approximately 11% of the general population and chronic migraine (CM) is suffered by around 1.4%-2.2% of the population worldwide.[4]

Personality traits are an individual's lifelong patterns relating to their environment within cultural norms. However, personality disorders differ from traits in which they tend to deviate from cultural norms and result in distress and dysfunction.[5] These traits are trends in behavior or attitude that tend to be present regardless of the situation.[6] Official criteria for diagnosing personality disorders are listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM)[5] and the fifth chapter of the International Classification of Diseases (ICD).[7] Personality traits assessed by DSM-IV[5] and the ICD-10[7] are grouped in 3 clusters (Table 1) based on similarity of symptomology, cluster A (odd, eccentric); cluster B (dramatic, emotional, erratic); and cluster C (anxious, fearful). The new version of DSM-V maintains the same classification.

Onabotulinumtoxin A (onabotA) is a widely used prophylactic treatment approved for patients with CM.[8] Predictor factors for onabotA response have been more heavily researched in recent decades. To date, several clinical predictors have been identified with varying results reported. It has been found that patients with imploding or ocular types of headaches were responders to onabotA, whereas those with exploding headaches were not.[9] It has been proposed that unilateral headache, presence of scalp allodynia, pericranial muscle tenderness, time of chronicity, ocular-type headache, and especially duration of illness, may predict treatment response to onabotA.[10] It still remains under study whether the above mentioned characteristics of CM might predict response to onabotA in patients with CM.[11] Additionally, in the past few years, plasma calcitonin gene-related peptide (CGRP) plasmatic levels[12] and trigeminal laser evoked potentials[13] have been placed as possible predictors of response. Though not currently available on the market, they show promise to use one day in routine clinical usage.[14]

Recent studies have shown that certain personality traits can be linked to migraine and CM,[15] which may have important implications in clinical management and treatment.[16] It has been further proposed that personality traits may predict treatment outcome in panic disorder.[17] Currently the influence of personality traits on onabotA response in patients with CM has not been studied. The aim of this study is to analyze the potential association between personality traits and onabotA response in patients with CM. We hypothesize that abnormal personality traits, specially cluster C traits, might be associated with non-response to onabotA.