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


Guidelines do not currently exist for combination therapy in CM. Monotherapy should be the rule in first-line prevention. Nevertheless, progress in the understanding of migraine supports the development of rational combination regimens, potentially applicable in a subgroup of patients who inadequately respond to individual monotherapies, that is, people with refractory migraine.[88] Preclinical data suggest a rationale for combining anti-CGRP mAbs with BTX-A for migraine prevention. If true, such synergistic effects are likely related to the modulation of CGRP-mediated signaling pathways at the level of C- and Aδ-fibers of the trigeminovascular system. However, the intriguing prospect of dual therapy with anti-CGRP mAbs and BTX-A should be substantiated through clinical trials that assess outcomes related to efficacy, safety, and cost-effectiveness. Over the next years, we will be in a better place to determine whether the dual administration of anti-CGRP mAbs and BTX-A has some evidence for benefit.