To the Editors

I would like to thank Dr. Finsterer for his interest in my article, and I welcome his comments [1]. I am happy that it has provoked a discussion on treating chronic migraine (CM) with botulinum toxin (BTX) by specialists other than neurologists. This article is the first to have assessed the actual situation in Poland [2], although the topic is of concern to many other countries also. The commercial market of BTX treatment for CM is continually developing, trying to meet patient needs and overcome barriers to accessing treatment. Based on labels, the use of products is not restricted to professionals experienced in treating CM. As a result, BTX is used to treat CM by neurologists, but also by aesthetic medicine practitioners (AMPs), orthopaedic surgeons, anaesthetists, and dentists. Any licensed physician can use BTX for various indications, including CM. My article looked at real-life practice and neither suggested nor approved treatment of CM with BTX by specialists other than neurologists. It did include a discussion of some weaknesses in today’s practice; however, it did not suggest it should either be prohibited or stigmatised. Physicians have the right to use a medication registered for a given indication to help their patient. I merely wish those practitioners using BTX to treat CM to know the diagnostic criteria, the principles of injection technique, and good patient management. The results map areas of improvement, at least in Poland, where the therapy was not reimbursed for 12 years. This led to the development of a commercial market for the treatment of CM in Poland, primarily owned by AMPs.

Undoubtedly, the diagnosis of migraine, especially CM, should be the domain of neurologists. Similarly, the management of patients with complicated migraine, especially those with a coexisting medication overuse headache, must be left in the hands of a neurologist. However, there is no reason why other specialists, including AMPs, could not perform the BTX injections after a neurologist has qualified the patient and provided that the procedure is performed correctly, following the PREEMPT protocol.

Patients might benefit if a neurologist avoids performing such a procedure, and instead cooperates with an AMP. There is an important reason for that. Due to the anatomical distinctiveness of each patient’s face, the injection, according to the PREEMPT protocol, can cause the patient’s appearance to alter unfavourably e.g. brow ptosis or the Mephisto symptom. This is especially important for women, and is sometimes the reason for discontinuing BTX for CM therapy. AMPs deal with such complications of BTX application much better than do most neurologists. Andrew Blumenfeld and I recently described an individualised approach for combining neurological and aesthetic treatments [3].

This preliminary study, performed using an online questionnaire, has many limitations. However, it might provide guidelines for further education directions among physicians in Poland. Given that every doctor in Poland, by law, can use BTX for CM, although they sometimes lack the knowledge and experience to do so correctly, it is surely safer to train those who do it anyway and encourage them to cooperate with neurologists regarding the diagnosis, qualification, and management of CM patients.