To determine whether the presence of Cranial Autonomic Symptoms (CAS) can be a predictor of the effect of Botox on chronic migraine (CM) headache and whether Botox improves CAS.

Chart review and survey of patients to determine whether the presence of CAS (≥ CAS, present to different degrees) predicts headache benefit from Botox in adults with CM. Improvement in headache was defined as 50% or more decrease in headache days.

• 93 patients (average age 45.6, 73.1% female) were enrolled in the study.

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85 had at least two rounds of Botox and were included in data analysis. 9 had no CAS at baseline, 5 (55.56%) had a 50% or more reduction in headache frequency.

34 had mild CAS at baseline, 10 (29.41%) had a 50% or more reduction in headache frequency.

42 had moderate or severe CAS at baseline, 9 (21.43%) had a 50% or more reduction in headache frequency.

37 of the 85 participants (39.78%) reported improvement in their CAS intensity.

Patients without CAS were more likely to improve from Botox treatment for chronic migraine, independently of medication overuse headache. Participants with moderate or severe CAS at baseline were less likely to respond to Botox treatment. It appears that Botox could improve CAS. It is possible that as the CAS improve from Botox, then the efficacy of Botox could continue to improve after multiple rounds.

Future studies will explore whether patients with moderate to severe CAS would require more rounds of Botox in order to show improvement in headache.