Do you continue to use Botox to treat chronic migraine in a patient who becomes pregnant?

First of all, my use of botulinum toxin for the preventive treatment of chronic migraine has dramatically decreased since I started working with the CGRP antibodies in the context of clinical trial research in 2012. I find them to be much more effective than botulinum toxin, equally well if not better tolerated, and much easier to administer. Generally, the relief obtained with CGRP antibodies is much more profound and much more stable than with botulinum toxin. Of course, they should not be used during pregnancy and for 6 months prior to conception. Here, I would not have a problem using botulinum toxin in the second or third trimester.

I would consider use in patients who are truly chronic and difficult to control with less risky medications. Always have a discussion with the OBGYN before you consider starting it. I've had some remarkable results using it in patients in the second and third trimesters. Weigh the pros/cons. Would it be more risky to inject patients with Botox or have them use analgesics >3-4x weekly to treat headaches? What is more harmful to the baby and the mother?

I have administered botox to several chronic migraineurs during their pregnancies (in all trimesters) without subsequent adverse outcomes for their neonates. Of course, this is a therapy I do not administer unless I have sufficient buy-in from the patient, in addition to their obstetrician. I have yet to see any literature showing any convincing reasons to avoid it in pregnant patients. As part of my current practice pattern, I actually administer it more frequently than CGRP antagonist Abs in pregnant patients.

I would consider using Botox in an appropriate patient during early pregnancy, but I have not done so before due to concerns about potential systemic and unexpected weakness.

I would refrain from recommending it primarily due to medical-legal considerations until more robust clinical publications on its safety are available. However, in extreme situations, I don't have any objections to it. Typically, I administer nerve blocks as needed, and in most cases, migraine patients will do much better during the second or third trimesters.