From the Guidelines
There are currently no specific studies that directly support the combined use of Botox (onabotulinumtoxinA) with Aimovig (erenumab) for migraine treatment, but the most recent guideline from 2024 1 suggests that both onabotulinumtoxinA and erenumab can be effective for the prevention of chronic migraine. However, in clinical practice, these treatments are sometimes used together for patients with chronic migraine who have not achieved adequate relief with either therapy alone. Botox is FDA-approved for chronic migraine (15 or more headache days per month) and involves quarterly injections into specific head and neck muscles to reduce migraine frequency. Aimovig, a calcitonin gene-related peptide (CGRP) receptor antagonist, is administered as a monthly self-injection of either 70mg or 140mg. When considering combination therapy, it's essential to note that these medications work through different mechanisms - Botox blocks neurotransmitter release from nerve endings and reduces muscle contraction, while Aimovig blocks the CGRP pathway involved in pain transmission. This mechanistic difference provides a theoretical basis for potential synergistic effects, as also suggested by the 2021 review on the diagnosis and management of migraine 1. Patients should discuss with their neurologist or headache specialist whether combination therapy might be appropriate for their specific situation, as insurance coverage for both treatments simultaneously can be challenging, and the combined cost may be substantial without adequate coverage. Some studies, such as the 2017 update on the uses of botulinum neurotoxin 1, have shown that onabotulinumtoxinA is effective for chronic migraine, but there is limited evidence on its use in combination with CGRP monoclonal antibodies like erenumab. Given the lack of direct evidence, the decision to use combination therapy should be based on individual patient needs and circumstances, taking into account the potential benefits and risks, as well as the guidance from recent clinical practice guidelines 1.
From the Research
Studies Supporting the Use of Botox with Aimovig
- The study 2 assesses the safety and efficacy of the combination of erenumab (Aimovig) and onabotulinum toxin A (Botox) for chronic migraine prevention, showing a significant reduction in monthly migraine and headache days.
- Although the study 3 does not directly investigate the combination of Botox with Aimovig, it discusses the use of botulinum toxin type A in the treatment of chronic migraine and its potential complementary role with monoclonal antibodies like Aimovig.
- The review 4 mentions the lack of evidence for combining CGRP-targeting therapeutics like Aimovig with botulinum toxin A, but suggests that individualized approaches using combination therapy could enhance treatment outcomes.
- The clinical trial protocol 5 investigates the efficacy and safety of combining eptinezumab or erenumab (Aimovig) with onabotulinumtoxinA (Botox) in refractory chronic migraine, aiming to provide a novel treatment option.
- The retrospective analysis 6 demonstrates favorable outcomes with the addition of erenumab (Aimovig) to patients receiving onabotulinumtoxinA (Botox) for the prevention of intractable chronic migraine without aura, showing a significant reduction in total monthly headache days and monthly migraine days.