Chronic Migraine — SCE Neurology MCQ

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ModerateHeadache & Facial PainChronic MigraineSCE Neurology

A 32-year-old woman with chronic migraine (22 headache days per month for 8 months) has failed adequate trials of propranolol, topiramate and amitriptyline. What is the next appropriate treatment per NICE guidelines?

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Correct answer: B — Botulinum toxin A injections

NICE TA260 recommends botulinum toxin type A (onabotulinumtoxinA) for chronic migraine (≥15 headache days/month for ≥3 months) in adults who have not responded to at least 3 prior preventive medications. It is administered as 31 injections across 7 head/neck muscle areas every 12 weeks. A: Gabapentin is not recommended for migraine prophylaxis by NICE. C: GON blocks may be useful but are not in the NICE pathway at this stage. D: Valproate is restricted in women of childbearing potential. E: CGRP monoclonal antibodies (e.g. fremanezumab, galcanezumab) are NICE-approved but typically positioned after botulinum toxin failure in the NHS commissioning pathway.

Reference: NICE TA260 Botulinum Toxin Type A for Chronic Migraine (2012); NICE CG150 (2012)