Dual Therapy With Anti-CGRP Monoclonal Antibodies and Botulinum Toxin for Migraine Prevention

Is There a Rationale?

Lanfranco Pellesi, MD; Thien P. Do, MD; Håkan Ashina, MD; Messoud Ashina, MD, PhD, DMSc; Rami Burstein, PhD


Headache. 2020;60(6):1056-1065. 

In This Article

Safety Concerns

Avoiding adverse events and drug-drug interactions is of primary concern when using combination therapy. At present, there is no available data to evaluate the safety profile of dual therapy with anti-CGRP mAbs and BTX-A. However, some theoretical safety concerns should be mentioned. The combined use of anti-CGRP mAbs and BTX-A may cause excessive antagonism of CGRP signaling pathways, resulting in less tolerability and more adverse events. Of note, BTX-A is administered as local injections, without any known CNS-related adverse events. Thus, it could be speculated that the adverse effects of dual therapy would primarily affect the head and neck regions, corresponding to the injection sites. Based on the physiological effects of CGRP,[15] peripheral adverse effects may include impaired tissue repair and wound healing as well as higher incidences of dermatitis.