Headache Direction and Aura Predict Migraine Responsiveness to Rimabotulinumtoxin B


  • From the San Antonio Military Medical Center, Fort Sam Houston, TX, USA (P.M. Grogan); Center for Neurological Care and Research, San Antonio, TX, USA (M.V. Alvarez); Department of Neurology, Mayo Clinic, Rochester, MN, USA (L. Jones).
  • The opinions expressed in this document are solely those of the authors and do not represent an endorsement by or the views of the United States Air Force, the United States Army, Department of Defense, or the United States Government.
  • Financial support: There was no financial support to fund this study.
  • Conflict of Interest: Dr. Grogan has received speaker honoraria compensation from Pfizer Inc and US World Meds. Dr. Alvarez has received speaker honoraria compensation from Teva, Pfizer Inc, and US World Meds. Dr. Jones has no financial disclosures. The authors have no conflicts of interest with this study.



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.


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.


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).


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).


Reported migraine directionality and presence of migrainous aura predict migraine headache responsiveness to rimabotulinumtoxin B injections.