NHS Salford Logo

Guidelines for the referral of patients for Botox® as a treatment for chronic, severe migraine. Botox® for migraine at Salford Royal Foundation Trust

Botox® (Botulinum toxin type A) is licensed for the treatment of chronic migraine and provides a potentially effective strategy in addition to the other therapeutic options for the treatment of this disabling condition. It costs significantly more than existing therapies and there is concern that patients may be referred for Botox before other simpler and effective medications have been considered.

The North West Specialist Commissioners Clinical Reference Group has developed a protocol for the use of Botox in migraine across the North West Neuroscience centres. The criteria for the referral of patients with chronic migraine and migraine with medication overuse are detailed below and apply to clinicians in primary and secondary care.

Patient groups: Referral criteria 1) Chronic migraine a. Headaches on ≥15 days per month (a minimum of 8 must be migrainous) b. No analgesic overuse (<10 days per month of analgesic or triptan use) c. Lifestyle changes implemented as appropriate, including withdrawal of caffeine d. Tried three (3) of the following (unless contraindicated) and continued each for 3 months without significant benefit (unless inappropriate, as judged by the clinician): i. Amitriptyline or Nortriptyline: 150mg o.n. or highest tolerated below that ii. A Betablocker: Propranolol SR 240mg a day or max tolerated below; or Metoprolol 200mg per day or max tolerated below that iii. Topiramate: highest tolerated dose up to 50mg b.d. iv. Sodium Valproate: highest tolerated dose up to 600 - 1000mg b.d. v. Gabapentin highest tolerated dose up to 600-1200mg tds vi. Lisinopril up to 20mg o.d. e. Relevant co-morbidities treated optimally 2) Chronic migraine and medication overuse a. Headaches on ≥15 days per month (a minimum of 8 must be migrainous) b. Analgesic use ≥15 days per month and/or triptan or opiate use ≥10 days per month c. No improvement with or intolerant of Topiramate up to 50mg b.d. d. Failed analgesic withdrawal as an outpatient, with appropriate pharmacological support; inpatient withdrawal of medication considered or tried if felt to be appropriate or likely to be effective e. Considered and/or tried a scalp nerve block (occipital nerve(s))as part of an analgesic-withdrawal regime) f. Relevant co-morbidities treated optimally

Referrals should be directed to: Dr Adam Zermansky, Consultant Neurologist or Dr Mark Kellett, Consultant Neurologist

Referrals should include a detailed history that covers the above referral criteria. Failure to document the above information will result in the return of the referral pending satisfactory completion. If patients satisfy the above criteria they should be asked to complete a daily headache diary starting in GP, as 2 months of headache diary information will be required prior to being started on treatment. Diaries should record the number of headache or migraine days per month, GP visits, A & E visits and other hospital attendances for head pain as well as the days that triptans are used. This should be continued throughout the treatment period.