Potential Layered Migraine Treatment Approaches to Research: Andrew Blumenfeld, MD

"In chronic migraine, the brain is sensitized, and it takes time to switch up these overactive pathways. We want to follow that, probably over a 6- to 12-month treatment period. We’re looking at a complicated trial because it’s going to be long duration.”

Investigators recently conducted a retrospective, longitudinal chart review of adults with chronic migraine (CM) treated with 2 or more consecutive onabotulinumtoxinA (Botox; Allergan/AbbVie) before at least 1 month of onabotulinumtoxinA plus calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb). Led by Andrew Blumenfeld, MD, patients demonstrated clinically meaningful treatment benefits with onabotulinumtoxinA alone and additive benefits after adding CGRP mAb.

Adverse events were reported in 28% of patients, with no new safety signals identified. The investigators concluded that more real-world studies and controlled trials are needed to further quantify potential benefits of this multimodal treatment paradigm. Blumenfeld, director of the Headache Center of Southern California, told NeurologyLive that a combination approach using onabotulinumtoxinA and atogepant, an investigational CGRP, would be an interesting study considering the impressive response rates atogepant has shown in clinical trials.

He sat down in this interview to discuss more about the potential research opportunities for these types of multimodal treatment strategies, the build of these clinical trials, and why they need plenty of time to fully show efficacy.