Headache direction and aura predict migraine responsiveness to rimabotulinumtoxin B

Objective To report a retrospective analysis of patients with migraine headaches treated with rimabotulinumtoxin B as preventive treatment, investigating an association between clinical responsiveness with migraine directionality and migrainous aura. Background The Phase III Research Evaluating Migraine Prophylaxis Therapy studies demonstrated onabotulinumtoxin A is effective in the preventive management of chronic migraine headaches. Jakubowski et al reported greater response to onabotulinumtoxin A in migraine patients reporting inward-directed head pain (imploding or ocular) compared with outward-directed head pain (exploding), suggesting subpopulations of patients may be better candidates for its use. No correlation was found between those reporting migrainous aura and onabotulinumtoxin A responsiveness. Methods One hundred twenty-eight migraine patients were identified who had received rimabotulinumtoxin B injections over an average of 22 months, or 7 injection cycles. Migraine directionality was reported as inward directed (imploding, n = 72), eye centered (ocular, n = 28), outward directed (exploding, n = 16), and mixed (n = 12). Results One hundred two out of one hundred twenty-eight patients (80%) improved; of these, 58 (57%) demonstrated a >75% reduction in monthly headache frequency (">75%-responders"), 76% of which noted sustained benefits >12 months with repeated injections every 10-12 weeks. Those reporting ocular- and imploding-directed headaches were significantly more likely to be >75%-responders, compared with exploding- and mixed-directed headaches (P <.0025). Patients with ocular-directed headaches were most likely to be sustained >75%-responders. Patients reporting migrainous aura were more likely to be >75%-responders (P =.0007). Those reporting exploding- and mixed-directed headaches were more likely to be nonresponders (P <.0001). Conclusions Reported migraine directionality and presence of migrainous aura predict migraine headache responsiveness to rimabotulinumtoxin B injections.