OnabotulinumtoxinA in chronic migraine: from the theory of clinical trials to clinical practice

The introduction of OnabotulinumtoxinA (OnabotA) in the treatment of chronic migraine has brought with it a significant change in the management of these patients. Its novel mechanism of action, the fact that it is administered as an injection and the need to repeat treatment and control regimens all suggest the need to modify the therapeutic strategy applied in this clinical situation. This article briefly reviews the main clinical evidence on the effectiveness of OnabotA in chronic migraine based on the clinical trials conducted to date. At the same time it also performs a critical analysis of the application of OnabotA in daily clinical practice. It includes the findings of a survey carried out on Spanish neurologists about their experience in the application of OnabotA in patients with chronic migraine in order to determine the real situation in our milieu. The main conclusions include the need to use suitable doses of OnabotA, together with appropriate injection points, the non-exclusion of patients with very frequent crises, concomitant preventive treatment or medication abuse, waiting up to 15 days in order to be able to observe the clinical effectiveness and not considering OnabotA as ineffective until after having performed 2-3 infiltration regimens.