Conditions: Chronic Migraine, Headache
Keywords: Migraine Onabotulinumtoxin A Botox Reconstitution Saline
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 68
Healthy volunteers: no

Brief summary:
A growing body of literature on the cosmetic use of OnabotulinumtoxinA has suggested that the use of preserved saline exerts a local anesthetic effect, and reduces the procedure discomfort when used in reconstitution in lieu of preservative-free saline. However, this has never been studied in chronic migraine.

While reducing discomfort is a desirable target in all procedures, it has a special importance in the use of OnabotulinumtoxinA for chronic migraine due to the numerous injection locations each session (31 sites) and the ubiquity of scalp tenderness in this population. In addition, the pain during procedure is a known migraine trigger for many of these patients.

We hypothesize that preserved saline (known as bacteriostatic saline) produces lower procedure-related discomfort when used as a dissolving solution for OnabotulinumtoxinA in individuals with chronic migraine as opposed to using preservative-free saline.

In addition, we hypothesize that reduction of procedure-relate pain during the injections will also result in reduced migraine/headache attacks in the week immediately following the procedure.

Detailed description:

Arms:
arm 1: OnabotulinumtoxinA (Botox) 200u will be reconstituted using 4 ml of preservative-free saline, as recommended by the manufacturer. 155-195 u of Onabotulinumtoxin A (Botox) will be injected in subjects with chronic migraine, consistent with FDA-approval indications, following the standard injection protocol (31 sites) arm 2: OnabotulinumtoxinA (Botox) 200u will be reconstituted using 4 ml of preservative saline (i.e. bacteriostatic saline). 155-195 u of Onabotulinumtoxin A (Botox) will be injected in subjects with chronic migraine, consistent with FDA-approval indications, following the standard injection protocol (31 sites).

Interventions: intervention 1: Preserved saline in reconstitution of Botox
Intervention descriptions: intervention 1: The intervention consists of using 4 ml of preserved saline for the reconstitution of OnabotuliniumtoxinA prior to its use in subjects with chronic migraine.

Protocol document:
Prot_SAP_001.pdf: 
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Onabotulinumtoxin Type A reconstitution with 
preserved versus preservative-free saline in chronic 
migraine (B-RECON). A randomized, double-blind trial. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   


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I. BACKGROUND AND SIGNIFICANCE 
Chronic migraine (CM) is a complex, progressive headache 
disorder affecting approximately 1.3‐2.4% of the general adult 
population. Onabotulinumtoxin type A (BoNTA) is considered an 
effective, FDA-approved, prophylactic treatment. Injections are 
administered at 31 sites of the head and neck, and treatment is 
repeated every 3 months. [2]  
 
BoNTA is manufactured as powder that requires reconstitution 
with normal saline prior to injection. The manufacturer of 
botulinum A exotoxin (Allergan Inc) has historically encouraged 
reconstitution with unpreserved saline. [3] However, the use of 
preserved saline (i.e. bacteriostatic) is common among 
practitioners to lengthen the shelf life of BoNTA (Botox ®) after 
reconstitution.  
 
A growing body of literature on the cosmetic use of BoNTA has 
suggested that preserved saline exerts a local anesthetic effect, 
and reduces the procedure discomfort when used in reconstitution 
in lieu of preservative-free saline. [3,4,5,6] However, this has 
never been studied in chronic migraine, and while reducing 
discomfort is a desirable target in all procedures, it has a special 
importance for the use of BoNTA in chronic migraineurs due to 
the numerous injection locations each session (31 sites) and the 
ubiquity of scalp tenderness in this population. [7] In addition, the 
pain during procedure is a known migraine trigger for many of 
these patients. In fact, one study showed that up to 5% report 
migraine attacks lasting more than 5 days as a side effect of 
BoNTA injection. [8] 
 
II. STUDY OBJECTIVES 
We hypothesize that bacteriostatic saline (a.k.a preserved saline) 
produces lower procedure-related discomfort when used as a 


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dissolving solution for BoNTA injections in individuals with chronic 
migraine as opposed to using preservative-free saline. 
In addition, we hypothesize that reduction of procedure-relate 
pain during BoNTA injection will also result in reduced 
migraine/headache attacks in the week immediately following the 
procedure. 
 
III. METHODS 
A. Study Design 
The study is a prospective, randomized, double-blind trial. 
Subjects will be enrolled consecutively at UHCC headache clinic 
from the practice of the two lead authors; AZ and LM who will be 
performing the injections. 
Two of the investigators, SH or AF, will perform the randomization 
through simulated, web-generated, coin toss. 
 
B. Study Materials 
Our preservative-free saline is a 0.9% sodium chloride injection. 
Each milliliter contained 9 mg of sodium chloride. The solution is 
supplied in 25-mL, single-dose vials. 
Our preservative-containing saline is a bacteriostatic 0.9% sodium 
chloride injection. Each milliliter contained 9 mg of sodium 
chloride and 9 mg of benzyl alcohol added as a bacteriostatic 
preservative. The solution is also supplied in 25-mL, single-dose 
vials. 
Both preserved saline and preservative-free saline are identical-
appearing, colorless solutions.  
BoNTA (Botox ® Allergan Inc) is a powder vial containing 200 u. 
Powder is reconstituted with 4 ml of normal saline and then drawn 
in four 1 ml syringes. All four syringes are used in a single patient 
in one session. 
 
C. Study Population 


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! Patients with diagnosis of chronic migraine receiving 
FDA-approved treatment with BoNTA injection as per 
standard protocol used in PREEMPT study [2]. 
Standard protocol consists of 31 injection sites, with 
total dose ranging from 155 u to 195u. 
 
! Exclusion criteria: 
1. Age < 18, or > 79 
2. Subjects whom BoNTA injections deviate from 
standard protocol for any reason, such as head/neck 
infection, head deformity, recent surgery…etc. 
 
! Study population will be randomized into two groups; 
preserved saline and preservative-free saline 
 
D. Study Procedures 
UHCC headache clinic performs 20-25 BoNTA injections a week 
on average. Enrollment plan is as following: on weekly basis, one 
of the investigators, either SH or AF, will contact all patients 
scheduled for BoNTA injections and explain the study’s objectives 
and details. If the subject agrees to enroll, he/she will be assigned 
a study serial number and will be randomized to one of the two 
groups. Randomization will be done through a simulated “coin 
flipper” website; www.random.org. Heads will be assigned to the 
preserved saline group, and tails will be assigned to the 
preservative-free saline group. SH and AF will keep the 
assignment sheet in a password-protected excel file that only they 
have access to.  
On the day of the procedure, informed consent will be confirmed 
and singed. Then, each subject will receive 10-15 minute session 
on the appropriate use of headache diary. 
Same randomizing investigator will reconstitute BoNTA vial 
(Allergan Inc) using one of the two identical solutions, and then 
hand it to the principal investigators; AZ or LM, who will be 


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performing the procedure using 30G 1/2’ needles. AZ ,LM, and 
the subject will all be blinded to which solution is used for 
reconstitution.  
Following the injections, subjects will be asked to rate procedure-
related pain using verbal pain rating scale (0 to 10). They will 
asked to maintain a 7-day headache diary (see supplementary). 
Prepaid mail envelopes will be provided to ensure the return of 
the diaries following their completion.  
 
IV. DATA COLLECTION 
Collected data will include age, gender, race, ethnicity, verbal 
pain rating scale, headache/migraine frequency and use of 
headache symptomatic medications. 
 
V. DATA ANALYSIS 
Sample size determination was calculated based on a minimally 
significant mean difference in verbal pain score of 1.5. To detect 
this difference with 90% power, alpha = .05; a total of 70 subjects 
(35 per group) will be required (SD=1.9). T-tests will be used to 
compare outcome of both groups. Statistical analysis will be 
carried by GB. 
 
VI. ETHICAL CONSIDERATIONS 
A. Informed Consent 
Informed consent will be obtained by investigators SH or AF at 
the time of the visit. Refusal of participation will not affect the 
treatment plan, and the subject will continue to receive BoNTA 
injections as scheduled, using the standard preservative-free 
saline. 
 
B. Risks and Side Effects 
Both solutions of normal saline are widely used in practice, and 
there are no known risks or side effects from using either.  


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Alerting subjects to the painful nature of the procedure and asking 
them to report that pain may exaggerate the resulting discomfort. 
Yet, we do not anticipate the discomfort to be sufficient to produce 
a significant clinical distress. The study carries inherent 
inconvenience related to filling headache diaries.  
 
C. Benefits to Subjects  
None 
 
D. Costs to Subjects 
None 
 
E. Compensation to Subject  
None 
 
F. Provisions for vulnerable subjects 
BoNTA injections is contraindicated in children <18 year-old, and 
in pregnancy. UHCC headache clinic does not participate in 
prisoners care. Thus, the study will not include vulnerable 
subjects. 
 
G. Subject Privacy and Data Confidentiality  
Information about study subjects will be kept confidential and 
managed according to the requirements of the Health Insurance 
Portability and Accountability Act of 1996 (HIPAA).  
A regulatory binder will be maintained for this study.  This will 
include items such as this protocol, the letter of approval from the 
IRB, the consents, and all other information pertinent to this study. 
The investigators will permit study-related monitoring, audits, and 
inspections by the SUNY Upstate IRB, the sponsor and 
government regulatory bodies of all study related documents (e.g. 
source documents, regulatory documents, data collection 
instruments, study data etc.).  


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VII. REFERENCES 
 
1. Castillo J, Muñoz P, Guitera V, Pascual J. Epidemiology of chronic daily 
headache in the general population. Headache: The Journal of Head and 
Face Pain. 1999 Mar;39(3):190-6. 
2. Dodick DW, Turkel CC, DeGryse RE, Aurora SK, Silberstein SD, Lipton RB, 
Diener HC, Brin MF. OnabotulinumtoxinA for treatment of chronic migraine: 
Pooled results from the double!blind, randomized, placebo!controlled phases 
of the PREEMPT clinical program. Headache: The Journal of Head and Face 
Pain. 2010 Jun;50(6):921-36. 
3. Alam M, Dover JS, Arndt KA. Pain associated with injection of botulinum A 
exotoxin reconstituted using isotonic sodium chloride with and without 
preservative: a double-blind, randomized controlled trial. Archives of 
dermatology. 2002 Apr 1;138(4):510-4.  
4. Van Laborde S, Dover JS, Moore M, Stewart B, Arndt KA, Alam M. Reduction 
in injection pain with botulinum toxin type B further diluted using saline with 
preservative: a double-blind, randomized controlled trial. Journal of the 
American Academy of Dermatology. 2003 Jun 1;48(6):875-7. 
5. Sarifakioglu N, Sarifakioglu E. Evaluating effects of preservative-containing 
saline solution on pain perception during botulinum toxin type-a injections at 
different locations: a prospective, single-blinded, randomized controlled trial. 
Aesthetic plastic surgery. 2005 Apr 1;29(2):113-5. 
6. Kwiat DM, Bersani TA, Bersani A. Increased patient comfort utilizing 
botulinum toxin type a reconstituted with preserved versus nonpreserved 
saline. Ophthalmic Plastic & Reconstructive Surgery. 2004 May 1;20(3):186-
9. 
7. Drummond PD, Drummond PD. Scalp tenderness and sensitivity to pain in 
migraine and tension headache. Headache: The Journal of Head and Face 
Pain. 1987 Jan;27(1):45-50. 
8. Khalil M, Zafar HW, Quarshie V, Ahmed F. Prospective analysis of the use of 
OnabotulinumtoxinA (BOTOX) in the treatment of chronic migraine; real-life 
data in 254 patients from Hull, UK. The journal of headache and pain. 2014 
Dec 1;15(1):54. 
 
 
VIII. APPENDICES