Conference Coverage

OnabotulinumtoxinA vs Topiramate for Chronic Migraine: Higher Patient Satisfaction Reported in US FORWARD Study

Ashton L. Stahl

Key Highlights

  • In the FORWARD study, patient treatment satisfaction was higher with onabotulinumtoxinA than with topiramate at weeks 6, 18, and 30.
  • Satisfaction advantages for onabotulinumtoxinA were also reported for headache frequency, headache severity, and ability to perform daily activities.
  • More participants said they would recommend onabotulinumtoxinA than topiramate at all evaluated time points.

In an abstract presented at the 2026 American Academy of Neurology Annual Meeting, patient treatment satisfaction favored onabotulinumtoxinA over topiramate in adults with chronic migraine enrolled in FORWARD, a US multicenter, randomized, parallel-group, open-label, prospective study.

Adults aged 18 to 65 years with chronic migraine, defined as at least 15 headache days per month, were randomized to receive either 155 U of onabotulinumtoxinA for 3 treatment cycles or topiramate up to 50 to 100 mg/day. Investigators used a patient treatment satisfaction questionnaire at weeks 6, 18, and 30 to assess overall satisfaction, as well as satisfaction with headache frequency, headache severity, and ability to perform daily activities. Each item was rated on a 5-point Likert scale ranging from extremely satisfied to extremely dissatisfied. The study also evaluated the proportion of participants who would recommend their assigned treatment.

Study Findings

A total of 282 participants were enrolled, including 140 assigned to onabotulinumtoxinA and 142 assigned to topiramate. Across all measured time points, a higher proportion of participants receiving onabotulinumtoxinA reported overall satisfaction than those receiving topiramate: 55.7% versus 28.2% at week 6, 65.0% versus 17.6% at week 18, and 59.3% versus 16.2% at week 30.

Similar patterns were reported across other patient-centered measures. Satisfaction with reduction in headache frequency was 55.7% versus 31.6% at week 6, 62.9% versus 17.6% at week 18, and 59.3% versus 16.2% at week 30 for onabotulinumtoxinA versus topiramate.

Satisfaction with headache severity was 54.2% versus 30.9%, 61.5% versus 19.0%, and 57.1% versus 15.5%, respectively. For the ability to perform daily activities, satisfaction rates were 59.3% versus 31.0% at week 6, 62.8% versus 18.3% at week 18, and 59.3% versus 16.9% at week 30.

More participants also said they would recommend onabotulinumtoxinA over topiramate: 60.0% versus 44.4% at week 6, 75.7% versus 19.7% at week 18, and 67.1% versus 16.9% at week 30. These findings are reported only in the study abstract.

Clinical Implications

According to the study authors, onabotulinumtoxinA treatment was associated with higher treatment satisfaction and greater willingness to recommend treatment than topiramate in chronic migraine. The authors also stated that these results were consistent with the overall FORWARD study findings, in which onabotulinumtoxinA showed greater effectiveness, defined as higher efficacy and tolerability, and greater clinical utility than topiramate.

Expert Commentary

“OnabotulinumtoxinA treatment was associated with higher treatment satisfaction and willingness to recommend treatment than topiramate. Results are consistent with overall study findings where onabotulinumtoxinA had greater effectiveness (higher efficacy and tolerability) and clinical utility than topiramate,” the researchers concluded.

Reference

Blumenfeld AM, Park TJ, Chan T, Shakhmantsir I, Rothrock JF. Patient treatment satisfaction with onabotulinumtoxinA versus topiramate for chronic migraine. Presented at: 2026 American Academy of Neurology Annual Meeting; Program No. P1.009. https://index.mirasmart.com/AAN2026/SearchResults.php?q=chronic+migraine&pg=1