Should Botox Treatment be more “Standardized”?

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Botox, generic name onabotulinumtoxinA, has become a common preventative treatment for migraine. But as we have noted before, you may get a different treatment depending on which doctor you go to.

During the last weeks of 2019, an anonymous questionnaire was sent to headache doctors to see just how they were using Botox, and the results might surprise you. But first, a little background.

A protocol has emerged to attempt to standardize Botox treatment, known as the PREEMPT protocol (named after Botox clinical trials). Allergan, the company that makes Botox, promotes this protocol as you can see here:

PREEMPT Paradigm overview

So there’s no doubt that Allergan wants doctors to use this protocol. But what did the study show?

Units? About 63% didn’t follow the protocol. “Proven sites”? Almost 58% didn’t follow the protocol. And 70% changed the injection sites. In fact, 77.5% of doctors said simply that they did not always follow the PREEMPT Paradigm.

Why not?

Going only by the abstract, the researchers explained: “The main reported reasons for changes in number, dose, and location of injections included adapting to the patients’ pain, anatomy, and preferences.”

That’s not really very specific, but the changes had to do with both doctor’s and patient’s “preferences”.

It should be noted that although some of these doctors were fairly new when it came to this treatment, many were quite experienced. In fact, 71.4% had more than three years’ experience.

The fact of the matter is that onabotulinumtoxinA research is moving on. Not just clinical trials, but also in the experience of the doctors providing the treatment. There is still a lot that we have to learn about Botox treatment – why does it work better for some patients than others? Could it be that PREEMPT is not the ideal for everyone?

Here you might find helpful some of the more recent articles on Botox treatment:

So the “why not” question is very important. If PREEMPT is the best treatment overall for migraine patients, that doesn’t mean that it’s the best for you. However, if it has the best evidence at the moment, it is a good starting place for most people. There’s a reason why Allergan is promoting this protocol.

But we should be careful to rule out the clinical experience of doctors, and the ongoing studies. What you should do is talk to your doctor and understand why she isn’t following PREEMPT in your case. She may have very good reasons. But it’s up to you to ask and get the answers you need before you start treatment.

Is your doctor adapting to “your anatomy”? Is your doctor simply not aware of PREEMPT? Has experience changed the way your doctor uses Botox for migraine? Ask!

The important message here from this study – be aware that Botox treatment is not standardized. Do your research and be aware of what your doctor is offering.

For more on this study: