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ASSESSMENT: BOTULINUM NEUROTOXIN IN THE TREATMENT OF AUTONOMIC DISORDERS AND PAIN (AN EVIDENCE-BASED REVIEW): REPORT OF THE THERAPEUTICS AND TECHNOLOGY ASSESSMENT SUBCOMMITTEE OF THE AMERICAN ACADEMY OF NEUROLOGY

ASSESSMENT: BOTULINUM NEUROTOXIN IN THE TREATMENT OF AUTONOMIC DISORDERS AND PAIN (AN EVIDENCE-BASED REVIEW): REPORT OF THE THERAPEUTICS AND TECHNOLOGY ASSESSMENT SUBCOMMITTEE OF THE AMERICAN ACADEMY OF NEUROLOGY To the Editor: Reports of the Therapeutics and Technology Assessment (TTA) Subcommittee of the American Academy of Neurology (AAN) are usually considered to be objective and definitive statements that are read and followed by large numbers of neurologists and are taken into consideration by many insurance companies. This makes reading parts of the latest assessment of botulinum neurotoxin (BoNT) in the treatment of autonomic disorders and pain particularly surprising and disappointing.1 The authors state that “Based on published Class I and Class II studies, BoNT injection is probably ineffective in the treatment of episodic migraine.”1 This statement is based on two studies which were well conducted, but used what we know to be suboptimal doses of BoNT. One study used up to 25 units of BoNT and the second one 7.5 to 50 units. Most headache specialists who utilize BoNT in their daily practice use an average of 100 units. Despite this, the report goes on to state unequivocally that “BoNT should not be considered in patients with episodic migraine and chronic tension-type headache.” We hope that the authors will issue a correction that will state that the treatment paradigms used in these studies were probably suboptimal and that no conclusion about the appropriateness of the use of BoNT in episodic migraine can be made.