Botulinum Toxin Type A Blockade of the Sphenopalatine Ganglion in Treatment-refractory Chronic Migraine
Botulinum Toxin Type A Blockade of the Sphenopalatine Ganglion in Treatment-refractory Chronic Migraine
This is a clinical trial to assess the efficacy of botox treatment of the sphenopalatine
 ganglion as an add-on treatment in drug resistant migraine. An injection targeting the
 ganglion is made possible by an image-guided device developed specifically for this purpose
 (MultiGuide) Study participants will be randomized to either placebo or botox after a 4 week
 run-in period. First, one injection will be given towards both the right and the left
 ganglion. After that there will be a follow-up of 12 weeks for efficacy and safety
 evaluation. The main efficacy measure is change in number of moderate to severe headache days
 before and after injection.
Inclusion Criteria:

 The participants must meet all of the inclusion criteria to participate in this study:

 1. Informed and written consent.

 2. Male or female, between 18 and 70 years of age

 3. Masters a Scandinavian language at level sufficient to fully understand the written
 and verbal study information

 4. Migraine, with or without aura, fulfilling the International Classification of
 Headache Disorders (ICHD) III criteria 1.3. for chronic migraine at time of inclusion

 5. Chronic migraine at least for a period of 1 year prior to inclusion

 6. Debut of episodic migraine before the age of 50, and chronic migraine before the age
 of 65.

 7. The condition is pharmacologically refractory as defined in this study as insufficient
 treatment effect, contraindication(s) or intolerable side effect(s) of at least 3
 medications from at least 2 of the following medication (drug) classes

 1. Beta-blockers

 2. RA(A)S-inhibitors

 3. Calcium-antagonists

 4. Antiepileptic drugs

 5. Tricyclic antidepressants

 6. Botulinum toxin A

 7. CGRP antagonists

 8. Subject has had no change in type, dosage or dose frequency of preventive headache
 medications < 3 months prior to baseline/screening, or a minimum of 5 half-lives,
 whichever is longer.

 9. Subject agrees to maintain current preventive headache medication regimens (no change
 in type, frequency, or dose) during the whole study period.

 10. In the case of women of childbearing potential (WOCBP) they have to commit to highly
 effective contraception in a period of 4 weeks after injection (for details, confer
 section 4.3)

 11. Ability to understand study procedures and to comply with them for the entire length
 of the study

 Exclusion Criteria:

 All candidates meeting any of the exclusion criteria at baseline or visit 2 will be
 excluded from study participation:

 1. Allergy or hypersensitivity reactions to marcaine, lidocaine, xylocaine, adrenaline,
 any botulinum toxin or similar substances.

 2. Subject is unable to differentiate migraine from other concomitant headaches.

 3. Subject with secondary headache conditions, with the exception of medication overuse
 headache.

 4. Non-responder in regular clinical practice to preventive medications from ≥6 of the
 following 7 drug classes:

 1. Beta-blockers

 2. RA(A)S-inhibitors

 3. Calcium-antagonists

 4. Antiepileptic drugs

 5. Tricyclic antidepressants

 6. Botulinum toxin A

 7. CGRP antagonists

 5. Subject has had a change in type, dosage or dose frequency of preventive headache
 medications < 3 months prior to baseline/screening, or a minimum of 5 half-lives,
 whichever is longer.

 6. Subject has had a change in type, dosage or dose frequency of preventive headache
 medications during the baseline period, eg. prior to IMP administration

 7. Botulinum toxin injections in the head and neck region, as part of migraine treatment
 or otherwise indicated on medical or cosmetic grounds, in the last 4 months before
 inclusion.

 8. The discontinuation of CGRP-antagonists within 3 months before study inclusion or 5
 half-lives, whichever is longer,

 9. Participation in a clinical study of a new chemical entity or a prescription medicine
 within 2 months before study inclusion or 5 half-lives, whichever is longer.

 10. Subject is currently participating or has participated in the last 3 months in another
 clinical study in which the subject has, is, or will be exposed to an investigational
 or non-investigational drug or device.

 11. Subject has had previous radiofrequency ablation, balloon compression, gamma knife, or
 chemical denervation (e.g. glycerol treatments) of the trigeminal ganglion or any
 branch of the trigeminal nerve.

 12. Subject has had previous radiofrequency ablation (including non-lesional pulsed
 radiofrequency), balloon compression, gamma knife, or chemical denervation (e.g.
 glycerol treatments) of the SPG.

 13. Subject has had blocks of short-acting anaesthetics of the SPG in the last 3 months.

 14. Subject is or has been treated with occipital nerve stimulation or deep brain
 stimulation.

 15. Ongoing abuse of drugs (including narcotics) or alcohol.

 16. More than 4 days of opioid use per month (including codeine and tramadol), and any use
 of barbiturates

 17. Treatment with pharmacological substances prior to SPG-injection that may interact
 with BTA (aminoglycosides, spectinomycin, neuromuscular blockers, both depolarizing
 agents (such as succinylcholine) or non-depolarizing (tubocurarine derivates), and
 anticholinesterases).

 18. Inadequate contraceptive use. Women of childbearing potential (WOCBP) who do not use
 highly effective contraception (HEC) or use other medication that may interact and/or
 otherwise reduce the efficacy of the contraceptive agents in use.

 19. Subject has undergone facial surgery in the area of the pterygopalatine fossa or
 zygomaticomaxillary at the planned injection site that, in the opinion of the
 Investigator, may lead to an inability to properly conduct the procedure.

 20. Facial anomaly or trauma which renders the procedure difficult.

 21. Subject currently has an active oral or dental abscess or a local infection at the
 site of injection based on present symptoms.

 22. Subject has been diagnosed with any major infectious processes such as osteomyelitis,
 or primary or secondary malignancies involving the face that have been active or
 required treatment in the past 6 months.

 23. Patients with comorbid psychiatric disorders with psychotic or other symptoms making
 compliance with the study protocol difficult, at the discretion of the investigator

 24. Patients exhibiting a high degree of comorbidity and/or frailty associated with
 reduced life expectancy or high likelihood of hospitalization, at the discretion of
 the investigator

 25. Patients with disorders that severely inhibits lacrimation, at the discretion of the
 investigator

 26. Patients with previous ischemic cardiovascular and cerebrovascular disorder with, in
 the opinion of the investigator, a moderate to high risk of new ischemic episodes.

 27. Known infection or history of human immunodeficiency virus, tuberculosis, or chronic
 hepatitis B or C infection.

 28. Subject has a history of bleeding disorders or coagulopathy, that, in the opinion of
 the Investigator, may lead to an inability to properly conduct the procedure.

 29. Unable to stop antithrombotic medication e.g. platelet aggregation inhibitors and/or
 anticoagulation therapy, prior to procedure.

 30. The patient cannot participate or successfully complete the study, in the opinion of
 their healthcare provider or the investigator, for any of the following reasons:

 -  mentally or legally incapacitated or unable to give consent for any reason

 -  in custody due to an administrative or a legal decision, under tutelage, or being
 admitted to a sanatorium or social institution

 -  has any other condition, which, in the opinion of the investigator, makes the
 patient inappropriate for inclusion in the study

 31. The patient is a study centre employee who is directly involved in the study or the
 relative of such an employee.