• Cristina Tassorelli, Gioacchino Tedeschi, P Sarchielli, Luigi Alberto Pini, Licia Grazzi, Pierangelo Geppetti, Marina De Tommaso, Marco Aguggia, P Cortelli, and Paolo Martelletti.
• a Headache Science Center , National Neurological Institute C. Mondino , Pavia , Italy.
• Expert Rev Neurother. 2018 Feb 1; 18 (2): 167-176.

IntroductionManagement of chronic migraine is challenging. OnabotulinumtoxinA (OBT-A) is the only medication licensed for prevention of chronic migraine, and has been widely adopted in clinical practice. Limited data is available on its long-term use. Areas covered: Data from controlled trials are combined with available data on the long-term use of OBT-A in real-life studies, with information obtained in a recent survey among Italian headache centers, and the clinical experience of the authors. Six areas were identified as relevant to patients with chronic migraine: 1) definition of responders to OBT-A; 2) management of responders to OBT-A; 3) optimal timing of prophylaxis with OBT-A; 4) position of OBT-A in prevention of chronic migraine; 5) management of medication overuse, and 6) patient education. Expert commentary: This review provides an update on the latest evidence regarding the long-term use of OBT-A in chronic migraine and analyzes the critical issues in the decision-making process that emerge from the analysis of the literature and routine practice. A treatment algorithm is proposed for the adoption in the daily practice.

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