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Abstract Details

Synergism of Anti-CGRP Monoclonal Antibodies and OnabotulinumtoxinA in the Treatment of Migraine
Headache
P10 - Poster Session 10 (8:00 AM-9:00 AM)
2-005
Chronic migraine is associated with impairment in quality of life, increased medical and psychiatric comorbidities, and accounts for significant health resource utilization. Many patients with chronic migraine do not achieve clinically meaningful improvement in their headache frequency and intensity with monotherapy. Therefore, the immense burden associated with chronic migraine calls for a multifaceted treatment approach targeting multiple aspects of migraine pathophysiology in hopes to improve patient outcomes. OnabotulinumtoxinA has been demonstrated to selectively inhibit unmyelinated C-fibers but not Aδ-meningeal nociceptors. Fremanezumab, an anti-CGRP monoclonal antibody, has been shown to prevent the activation of Aδ-fibers but not C-fibers. Therefore, concurrent use of anti-CGRP with onabotulinumtoxinA may have a synergistic effect with targeting both Aδ-fibers and C-fibers. 
To further evaluate if the response to anti-CGRP monoclonal antibodies (mAbs) is enhanced with concurrent onabotulinumtoxinA treatment with regard to monthly migraine days (MMD) in patients with chronic migraine. 
The electronic medical records of patients concurrently treated with anti-CGRP mAbs and onabotulinumtoxinA were extracted (n=121). The cohort’s (92.56% female, 51.19 ± 13.59 years old, 28.13 ± 4.04 baseline MMD) MMD were examined at baseline, before and after monotherapy of anti-CGRP mAb and onabotulinumtoxinA, and following combined treatment for at least 2 sets of onabotulinumtoxinA injections. The reduction of MMD for each treatment group were compared with the Kruskal-Wallis and Dunn’s comparison tests. 
Anti-CGRP mAb alone reduced an average of 13.51 ± 6.47 migraine days per month, a non-significant difference (p>0.99) from the 13.25 ± 7.35 MMD reduced from onabotulinumtoxinA treatment. Concurrent treatment of both anti-CGRP mAb and onabotulinumtoxinA resulted in an average reduction of 22.61 ± 5.62 MMD from baseline. The reduction from the monotherapies were significantly different from the dual therapy (p>0.0001). 
Combination therapy of anti-CGRP monoclonal antibodies and onabotulinumtoxinA may be more efficacious than monotherapy, possibly due to their synergistic mechanisms of action.
Authors/Disclosures
Elise Ruth Hennessy, MD (Penn State Health)
PRESENTER
Dr. Hennessy has nothing to disclose.
Amira Salim (Cleveland Clinic Foundation - Main Campus) Miss Salim has nothing to disclose.
Sudipa Biswas, MD (Cleveland Clinic) Dr. Biswas has nothing to disclose.
Aarushi Suneja, MD (Cleveland Clinic Foundation) Dr. Suneja has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Abbvie. Dr. Suneja has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Abbvie.
Maryann Mays, MD, FAAN (Cleveland Clinic) Dr. Mays has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for CoolTech Medical. Dr. Mays has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Abbvie. The institution of Dr. Mays has received research support from Amgen.
Zubair Ahmed, MD (Apex Medical Research ) Dr. Ahmed has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Eli Lilly. Dr. Ahmed has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Abbvie. Dr. Ahmed has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Biohaven.
Ignacio Mata Ignacio Mata has nothing to disclose.